Basic Information
| Provider Information | |||||||||
| NPI: | 1447369202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEATING | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 615 E PRINCETON ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073035781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 615 E PRINCETON ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073035781 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME69882 | FL | N | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | ME69882 | FL | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 156281 | 05 | LA | MEDICAID | 1981346 | 05 | NY | MEDICAID | 379399100 | 05 | FL | MEDICAID |