Basic Information
| Provider Information | |||||||||
| NPI: | 1730372350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARY KEOGH, MD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 7627 | ||||||||
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| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516337211 | ||||||||
| FaxNumber: | 2514106079 | ||||||||
| Practice Location | |||||||||
| Address1: | 3715 HIGHWAY 280 431 N | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516337211 | ||||||||
| FaxNumber: | 2514106079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | KEOGH | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2516337211 | ||||||||
| 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 | 2081P2900X | MD24656 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.