DR. KEITH DAVID CLANCY (NPI# 1164482303) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1164482303 |
| Entity Type | Individual |
| Full Name | DR. KEITH DAVID CLANCY |
| Credential | M.D. |
| Practice Address |
7900 W Jefferson Blvd Ste 306 Fort Wayne IN 46804-4128 |
| Mailing Address |
6920 Pointe Inverness Way Ste 200 Fort Wayne IN 46804-7934 |
| Practice Telephone | 2604583610 |
| Practice Fax Number | 2604583611 |
| Mailing Telephone | 2604793514 |
| Mailing Fax Number | 2604793520 |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2020-09-23 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 208600000X | Surgery | 01079569A | IN | Allopathic & Osteopathic Physicians |
| N | 208600000X | Surgery | 036.090092 | IL | Allopathic & Osteopathic Physicians |
| N | 208600000X | Surgery | 35.123491 | OH | Allopathic & Osteopathic Physicians |
| N | 208600000X | Surgery | MD067578-L | PA | Allopathic & Osteopathic Physicians |
| N | 2086S0102X |
Surgery Specialization: Surgical Critical Care |
35.123491 | OH | Allopathic & Osteopathic Physicians |
| N | 2086S0102X |
Surgery Specialization: Surgical Critical Care |
MD067578-L | PA | Allopathic & Osteopathic Physicians |
| Y | 2086S0127X |
Surgery Specialization: Trauma Surgery |
01079569A | IN | Allopathic & Osteopathic Physicians |
| N | 2086S0127X |
Surgery Specialization: Trauma Surgery |
MD067578-L | PA | Allopathic & Osteopathic Physicians |
| N | 2086S0127X |
Surgery Specialization: Trauma Surgery |
036.090092 | IL | Allopathic & Osteopathic Physicians |
| N | 2086S0127X |
Surgery Specialization: Trauma Surgery |
35.123491 | OH | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| PA | CAPITAL BLUE CROSS-WMG | 01122002 | 01 |
| PA | MAMSI-WMG | 491516 | 01 |
| PA | GEISINGER | 56845 | 01 |
| PA | AETNA | 7731206 | 01 |
| PA | AMERIHEALTH MERCY-WMG | 20006031 | 01 |
| PA | HIGHMARK BLUE SHIELD | 562564 | 01 |
| MD | CAREFIRST MD BCBS | 610201 | 01 |
| PA | JOHNS HOPKINS | 039983 | 01 |
| PA | AMERIHEALTH 65 PA | 0342984000 | 01 |
| PA | 001757641 | 05 | |
| PA | UNISON-WMG | 117558 | 01 |
| PA | GATEWAY-WMG | 1506063 | 01 |
| Street Address |
7900 W JEFFERSON BLVD STE 306 |
| City | FORT WAYNE |
| State | IN |
| Zip Code | 46804-4128 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1467019349 | Ford W. Lee | Nurse Practitioner | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2019-05-25 |
| 1710462270 | Brittony C. Rogers | Nurse Practitioner | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2018-10-01 |
| 1932688405 | Matthew P. Cummins | Physician Assistant | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2018-08-07 |
| 1811485956 | Dasmyn L. Dismuke | Physician Assistant | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2018-04-24 |
| 1467968172 | Jamie D. Miller | Physician Assistant | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2017-12-18 |
| 1891219507 | Kelly A. Stabenau | Physician Assistant | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2017-08-03 |
| 1922521459 | Neil J. Shorb | Nurse Practitioner | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2017-07-17 |
| 1093166738 | Carolyn L. Hanrahan | Physician Assistant | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2016-06-23 |
| 1184099988 | Molly M. Sabol | Physician Assistant | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2015-12-04 |
| 1124302633 | Geoffrey A. Mccord | Nurse Practitioner | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2011-10-03 |
| Find all providers in the same location | ||||
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1396350344 | Derek Mumaw | Physical Therapist | 8420 Illinois Rd, Fort Wayne, IN 46804 | 2020-09-15 |
| 1942840228 | Erin M Mason | Behavior Technician | 5601 Coventry Ln, Fort Wayne, IN 46804 | 2020-01-14 |
| 1346880879 | Emily A Abdalla | Behavior Technician | 5601 Coventry Ln., Fort Wayne, IN 46804 | 2020-01-13 |
| 1083265433 | Fort Wayne Endodontics | Dentist | 9407 Illinois Rd, Fort Wayne, IN 46804 | 2019-09-26 |
| 1689140949 | Harrison Dental Group II, LLC | Dentist | 1333 Getz Rd, Fort Wayne, IN 46804 | 2018-10-15 |
| 1346731908 | Erin Nicole Zimmerman | Nurse Practitioner | 10170 Illinois Rd # 14, Fort Wayne, IN 46804 | 2018-05-19 |
| 1417446022 | Mary Harrington | Physical Therapist | 3320 Copper Hill Run, Fort Wayne, IN 46804 | 2018-05-09 |
| 1942701214 | Joshawa Todd Torres | Marriage & Family Therapist | 5651 Coventry Ln # 116, Fort Wayne, IN 46804 | 2018-02-22 |
| 1194235408 | Mitchell Kory Meyer | Specialist/Technologist | 9125 Yellow Tree Ct, Fort Wayne, IN 46804 | 2017-10-02 |
| 1902324916 | Emily Rene Sagstetter | Specialist/Technologist | 6034 Liberty Glade Ct, Fort Wayne, IN 46804 | 2017-08-30 |
| Find all providers in zip 46804 | ||||
| Taxonomy Code | 2086S0127X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Surgery |
| Specialization | Trauma Surgery |
| Trauma surgery is a recognized subspecialty of general surgery. Trauma surgeons are physicians who have completed a five-year general surgery residency and usually continue with a one to two year fellowship in trauma and/or surgical critical care, typically leading to additional board certification in surgical critical care. There is no trauma surgery board certification at this point. To obtain board certification in surgical critical care, a fellowship in surgical critical care or anesthesiology critical care must be completed during or after general surgery residency. |
| Notes: Source: American Board of Surgery, 2007 [1/1/2008: definition added, source added] Additional Resources: http://www.absurgery.org/. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1528357118 | Cecivon Arreola-garcia | Surgery | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2011-04-04 |
| 1306098439 | Constantine G Saites | Surgery | 7900 W Jefferson Blvd Ste 306, Fort Wayne, IN 46804-4128 | 2008-10-21 |
| 1669576997 | Parkview Hospital, Inc. | Surgery | 11109 Parkview Plaza Dr, Trauma Unit, Fort Wayne, IN 46845-1701 | 2006-09-08 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1881030450 | Thaddeus Joseph Puzio | Surgery | 1801 N Senate Blvd Dept Surgery, Indianapolis, IN 46202 | 2013-05-22 |
| 1700324720 | Brittlebank Acute Trauma Specialists LLC | Surgery | 3901 S 7th St, Terre Haute, IN 47802-5709 | 2017-02-09 |
| 1295185858 | Wabash Valley Surgical Associates LLC | Surgery | 3901 S 7th St, Terre Haute, IN 47802-5709 | 2016-06-15 |
| 1912305699 | Baikal Surgical Specialists LLC | Surgery | 3901 S 7th St, Terre Haute, IN 47802-5709 | 2014-12-12 |
| 1487717120 | John Matthew Radosevich | Surgery | 807 Glendale Blvd, Valparaiso, IN 46383-3718 | 2006-12-17 |
| City | FORT WAYNE |
| Zip Code | 46804 |
Please comment or provide details below to improve the information on DR. KEITH DAVID CLANCY.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.