Basic Information
| Provider Information | |||||||||
| NPI: | 1790779577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEOGH | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4619 SPRING HILL AVE | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366085709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516337211 | ||||||||
| FaxNumber: | 2514106079 | ||||||||
| Practice Location | |||||||||
| Address1: | 3715 HIGHWAY 280-431 NORTH | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516337211 | ||||||||
| FaxNumber: | 2514106079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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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 | 2081P2900X | 24656 | AL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051005486 | 01 | AL | BCBS | OTHER |