Provider Demographics
NPI:1487609558
Name:POOLE, KEITH A (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:POOLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51339 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-9119
Mailing Address - Country:US
Mailing Address - Phone:740-635-4572
Mailing Address - Fax:740-635-4575
Practice Address - Street 1:55741 NATIONAL ROAD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912
Practice Address - Country:US
Practice Address - Phone:740-635-4572
Practice Address - Fax:740-635-4575
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1840207Q00000X
OH34.007929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1841034000Medicaid
OH2345144Medicaid
WV1841034000Medicaid
WV7305571Medicare PIN
OH2345144Medicaid
WV4090131Medicare ID - Type Unspecified