Provider Demographics
NPI:1912900879
Name:RADIE KEANE, KATHY (MD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:
Last Name:RADIE KEANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54589
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0589
Mailing Address - Country:US
Mailing Address - Phone:508-941-7450
Mailing Address - Fax:508-941-6205
Practice Address - Street 1:825 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5707
Practice Address - Country:US
Practice Address - Phone:401-521-9700
Practice Address - Fax:401-751-1686
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI0885162085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7004866Medicaid
RI920005159OtherRR MEDICARE
MA110081540AMedicaid
RIE48445Medicare UPIN
MA110081540AMedicaid
MA000349202Medicare PIN
MA110081540AMedicaid