Healthcare Provider Details

I. General information

NPI: 1487146692
Provider Name (Legal Business Name): MICAH JUDD KEENO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD FL 1
GREENVILLE SC
29605-4210
US

IV. Provider business mailing address

300 E MCBEE AVE STE 300
GREENVILLE SC
29601-2899
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-7899
  • Fax: 864-455-5474
Mailing address:
  • Phone: 864-522-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number94688
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.015270
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: