Healthcare Provider Details

I. General information

NPI: 1659346740
Provider Name (Legal Business Name): KEITH E MACKSOUD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 OLD LOUISQUISSET PIKE
LINCOLN RI
02865-4516
US

IV. Provider business mailing address

1817 OLD LOUISQUISSET PIKE
LINCOLN RI
02865-4516
US

V. Phone/Fax

Practice location:
  • Phone: 401-727-2443
  • Fax: 401-729-3476
Mailing address:
  • Phone: 401-727-2443
  • Fax: 401-729-3476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA24719
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: