Basic Information
| Provider Information | |||||||||
| NPI: | 1194073460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | WATSON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11766 HIGHWAY 27 | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307475989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068573915 | ||||||||
| FaxNumber: | 7068575638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2012 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 076603 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.