Basic Information
| Provider Information | |||||||||
| NPI: | 1164482303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLANCY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 W JEFFERSON BLVD STE 306 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604583610 | ||||||||
| FaxNumber: | 2604583611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD067578-L | PA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 036.090092 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 35.123491 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 01079569A | IN | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | MD067578-L | PA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0102X | 35.123491 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 036.090092 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | MD067578-L | PA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | 35.123491 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0127X | 01079569A | IN | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001757641 | 05 | PA | MEDICAID | 117558 | 01 | PA | UNISON-WMG | OTHER | 562564 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 039983 | 01 | PA | JOHNS HOPKINS | OTHER | 20006031 | 01 | PA | AMERIHEALTH MERCY-WMG | OTHER | 7731206 | 01 | PA | AETNA | OTHER | 01122002 | 01 | PA | CAPITAL BLUE CROSS-WMG | OTHER | 491516 | 01 | PA | MAMSI-WMG | OTHER | 610201 | 01 | MD | CAREFIRST MD BCBS | OTHER | 1506063 | 01 | PA | GATEWAY-WMG | OTHER | 56845 | 01 | PA | GEISINGER | OTHER | 0342984000 | 01 | PA | AMERIHEALTH 65 PA | OTHER |