1447256482 NPI number — GERALD E KEIGHTLEY M.D.

Table of content: GERALD E KEIGHTLEY M.D. (NPI 1447256482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447256482 NPI number — GERALD E KEIGHTLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEIGHTLEY
Provider First Name:
GERALD
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447256482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 71122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28272-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-559-6980
Provider Business Mailing Address Fax Number:
804-559-6982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8400 N RUN MEDICAL DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MECHANICSVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-559-6980
Provider Business Practice Location Address Fax Number:
804-559-6982
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  0101047191 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 228371 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 6041396 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 597421 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 31247 . This is a "CARENET" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541497804 . This is a "TRICARE CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 202213 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 59426 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 052647 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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