Provider Demographics
NPI:1124140066
Name:KEENE, JOHN RUSSELL (RT(R))
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RUSSELL
Last Name:KEENE
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:RUSTY
Other - Last Name:KEENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RT(R)
Mailing Address - Street 1:200 PLAIN DEALING FARM LN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-2501
Mailing Address - Country:US
Mailing Address - Phone:410-758-0996
Mailing Address - Fax:
Practice Address - Street 1:10 N GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR00009702471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography