Healthcare Provider Details

I. General information

NPI: 1871798553
Provider Name (Legal Business Name): GRANT EDWARD KEENEY M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4234
US

IV. Provider business mailing address

317 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4234
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1418
  • Fax:
Mailing address:
  • Phone: 253-403-1418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number55563020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberMD60448459
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD60448459
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: