Basic Information
| Provider Information | |||||||||
| NPI: | 1669489472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEOGH | ||||||||
| FirstName: | BART | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 19020 33RD AVE W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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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 | 2085N0700X | MD00040084 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD00040084 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | S-7976 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | S-7976 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 218043 | 01 | WA | LNI PROVIDER ID | OTHER | 218046 | 01 | WA | LNI PROVIDER ID | OTHER | 218040 | 01 | WA | LNI PROVIDER ID | OTHER | 1007471 | 05 | AK | MEDICAID | 8288359 | 05 | WA | MEDICAID |