Provider Demographics
NPI:1629063219
Name:CALLAHAN, KEITH L (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:L
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:390 TOLL GATE RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4326
Mailing Address - Country:US
Mailing Address - Phone:401-921-5672
Mailing Address - Fax:401-921-5679
Practice Address - Street 1:390 TOLL GATE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4326
Practice Address - Country:US
Practice Address - Phone:401-921-5672
Practice Address - Fax:401-921-5679
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9201212OtherCIGNA
RI496-667OtherTUFTS
RIAA98861OtherHARVARD PILGRIM
RI32250-6OtherBLUE CROSS
RI414283OtherBLUE CHIP
RI810900591OtherMULTIPLAN/PHCS
RI32250-6OtherBLUE CROSS
RI007059646Medicare PIN