Basic Information
| Provider Information | |||||||||
| NPI: | 1447389697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEITH B. HUCKABY, M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 519 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | THOMASTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302863504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066471752 | ||||||||
| FaxNumber: | 7066470339 | ||||||||
| Practice Location | |||||||||
| Address1: | 519 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | THOMASTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302863504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066471752 | ||||||||
| FaxNumber: | 7066470339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUCKABY | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7066471752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M. D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003757 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 00304983A | 05 | GA | MEDICAID |