Basic Information
| Provider Information | |||||||||
| NPI: | 1760459887 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITHLEY | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107295100 | ||||||||
| FaxNumber: | 4107295156 | ||||||||
| Practice Location | |||||||||
| Address1: | 1509 RITCHIE HWY | ||||||||
| Address2: | |||||||||
| City: | ARNOLD | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210122742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107577600 | ||||||||
| FaxNumber: | 4106268043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 01/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00044294 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D0056088 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 011989 | 01 | MD | JHHC PROVIDER NUMBER | OTHER | 7605-0102 | 01 | MD | CAREFIRST BLUECHOICE | OTHER | 697600000 | 05 | MD | MEDICAID | 8196530 | 01 | MD | MAMSI PRIMARY CARE | OTHER | P00726152 | 01 | MD | RAILROAD MEDICARE | OTHER | 6881582 | 01 | MD | AETNA CAPITATED | OTHER | 2196530 | 01 | MD | MAMSI SPECIALIST | OTHER | 606832-05 | 01 | MD | CAREFIRST MD RENDERING | OTHER | 7480124 | 01 | MD | AETNA FEE FOR SERVICE | OTHER | 2026499 | 01 | MD | UHC PROVIDER NUMBER | OTHER | P18514 | 01 | MD | CAREFIRST MPOS | OTHER |