MEDICARE: KEAGLE MEDICAL, INC.

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	2086S0122X	Plastic and Reconstructive Surgery Physician	A64773	CA

General Provider Information

NPI Number	:	1770720641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEAGLE MEDICAL, INC.

Provider Business Mailing Address
First Line	:	2614 ARTHUR ST STE C
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-3990
Country	:	US
Telephone Number	:	213-250-1300
Fax Number	:

Provider Business Practice Location Address
First Line	:	2614 ARTHUR ST STE C
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-3990
Country	:	US
Telephone Number	:	213-250-1300
Fax Number	:	213-559-9473

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JENNIFER NEWMAN KEAGLE
Credential	:	M.D.
Telephone Number	:	213-505-6012

Provider Enumeration Date	:	01/14/2009
Last Update Date	:	09/27/2024

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