Healthcare Provider Details

I. General information

NPI: 1487609558
Provider Name (Legal Business Name): KEITH A POOLE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55741 NATIONAL ROAD
BRIDGEPORT OH
43912
US

IV. Provider business mailing address

51339 NATIONAL RD
SAINT CLAIRSVILLE OH
43950-9119
US

V. Phone/Fax

Practice location:
  • Phone: 740-635-4572
  • Fax: 740-635-4575
Mailing address:
  • Phone: 740-635-4572
  • Fax: 740-635-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1840
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.007929
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: