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General NPI Number Information
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NPI Number | 1164482303
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Entity Type | Individual
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Provider Name | KEITH DAVID CLANCY M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/23/2006
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Last Update Date | 09/23/2020
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Provider Practice Location Address
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Address Line | 7900 W JEFFERSON BLVD STE 306
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City | FORT WAYNE
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State | IN
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Zip | 46804-4128
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Country | US
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Telephone | 260-458-3610
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Fax | 260-458-3611
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Provider Business Mailing Address
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Address Line | 6920 POINTE INVERNESS WAY STE 200
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City | FORT WAYNE
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State | IN
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Zip | 46804-7934
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Country | US
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Telephone | 260-479-3514
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Fax | 260-479-3520
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD067578-L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036.090092
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 35.123491
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License Number State | OH
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Taxonomy #4
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 01079569A
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License Number State | IN
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Taxonomy #5
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Taxonomy Code | 2086S0102X
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Taxonomy Name | Surgical Critical Care Physician
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License Number | MD067578-L
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License Number State | PA
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Taxonomy #6
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Taxonomy Code | 2086S0102X
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Taxonomy Name | Surgical Critical Care Physician
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License Number | 35.123491
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License Number State | OH
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Taxonomy #7
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number | 036.090092
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License Number State | IL
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Taxonomy #8
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number | MD067578-L
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License Number State | PA
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Taxonomy #9
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number | 35.123491
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License Number State | OH
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Taxonomy #10
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number | 01079569A
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License Number State | IN
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