MEDICARE: DR. GORDON W. KEATING M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD00011867	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	K077	OTHER	WA	REGEANCE BLUE SHIELD

General Provider Information

NPI Number	:	1376636886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON W. KEATING M.D.

Provider Business Mailing Address
First Line	:	1906 FEDERAL AVE EAST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98102-4239
Country	:	US
Telephone Number	:	206-320-9100
Fax Number	:	206-320-9099

Provider Business Practice Location Address
First Line	:	1906 FEDERAL AVE EAST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98102-4239
Country	:	US
Telephone Number	:	206-320-9100
Fax Number	:	206-320-9099

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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