Healthcare Provider Details

I. General information

NPI: 1235785239
Provider Name (Legal Business Name): MARY KEOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 VETERANS MEMORIAL PKWY
EAST PROVIDENCE RI
02914-5017
US

IV. Provider business mailing address

425 PLAINFIELD ST
PROVIDENCE RI
02909-4457
US

V. Phone/Fax

Practice location:
  • Phone: 401-429-6290
  • Fax:
Mailing address:
  • Phone: 401-316-8344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT03193
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: