Basic Information
| Provider Information | |||||||||
| NPI: | 1083630834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEEDY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307840 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1210 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407412112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068644040 | ||||||||
| FaxNumber: | 6068643500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 05/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 26392 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 26392 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 4000501 | 01 | KY | MEDICARE GROUP NUMBER | OTHER | 36000818 | 01 | KY | ASC MEDICAID GROUP# | OTHER | 64263924 | 05 | KY | MEDICAID | CB5773 | 01 | GA | RR MEDICARE GROUP# | OTHER | 37903705 | 01 | KY | MEDICAID LAB GROUP# | OTHER | 4000501 | 01 | KY | MEDICARE LAB GROUP# | OTHER | 060086348 | 01 | GA | RR MEDICARE PIN# | OTHER | ASC 1019 | 01 | KY | ASC MEDICARE GROUP# | OTHER |