Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | PT03193 | RI |
Y | 213ES0000X | Sports Medicine | PT03193 | RI |
NPI | 1235785239 |
---|---|
Provider Name | Mary Keough |
First Address | Providence, RI 02908-2810 |
Second Address | North Smithfield, RI 02896-6865 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2019 |
Last Update Date | 15/08/2019 |