MEDICARE: KEEGAN DOUGLAS SHANNON PT, DPT

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	225100000X	Physical Therapist	5501303485	MI

General Provider Information

NPI Number	:	1861224412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEEGAN DOUGLAS SHANNON PT, DPT

Provider Business Mailing Address
First Line	:	PO BOX 419885
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-9885
Country	:	US
Telephone Number	:	914-294-4050
Fax Number	:	631-760-8306

Provider Business Practice Location Address
First Line	:	11160 WJ PRESLEY PKWY STE 103
Second Line	:
City	:	ALLENDALE
State	:	MI
Zip	:	49401-8075
Country	:	US
Telephone Number	:	978-602-7431
Fax Number	:

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

Provider Enumeration Date	:	08/14/2024
Last Update Date	:	08/14/2024

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