Basic Information
| Provider Information | |||||||||
| NPI: | 1477582377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEIZER | ||||||||
| FirstName: | LAVERNE | ||||||||
| MiddleName: | RICHFORD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12938 | ||||||||
| Address2: | C/O CLINIC MANAGEMENT | ||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307030128 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 RED BUD RD NE | ||||||||
| Address2: | |||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307016008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068794776 | ||||||||
| FaxNumber: | 7068795841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 038825 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000632343J | 05 | GA | MEDICAID | 000632343H | 05 | GA | MEDICAID |