Basic Information
| Provider Information | |||||||||
| NPI: | 1861711079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKEOWN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | NORMAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NORMAN | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4700 WATERS AVE FL 1 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508712 | ||||||||
| FaxNumber: | 9123508753 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 OKATIE CENTER BLVD S STE 101 | ||||||||
| Address2: | |||||||||
| City: | OKATIE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299097555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508712 | ||||||||
| FaxNumber: | 9123508753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ML60163192 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 080224 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 40593 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 2016-00238 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 2016-00238 | NC | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | 40593 | SC | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | 080224 | GA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1861711079 | 05 | NC | MEDICAID |