Healthcare Provider Details

I. General information

NPI: 1447444211
Provider Name (Legal Business Name): ANDREW KEOGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 LINWOOD AVE
WILLIAMSVILLE NY
14221-6501
US

IV. Provider business mailing address

673 MOORE AVE
BUFFALO NY
14223-1803
US

V. Phone/Fax

Practice location:
  • Phone: 716-626-9016
  • Fax: 716-626-4271
Mailing address:
  • Phone: 716-681-5077
  • Fax: 716-681-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number074180
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: