Basic Information
| Provider Information | |||||||||
| NPI: | 1699775825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEAGY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2153 VALLEYGATE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106720350 | ||||||||
| FaxNumber: | 9106720355 | ||||||||
| Practice Location | |||||||||
| Address1: | 2153 VALLEYGATE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106720350 | ||||||||
| FaxNumber: | 9106720355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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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 | 208G00000X | 34003768 | OH | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 2008-00484 | NC | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 2467272 | 05 | OH | MEDICAID |