Basic Information
Provider Information | |||||||||
NPI: | 1992964316 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUY | ||||||||
FirstName: | KEYTESHIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10403 HOSPITAL DR STE G4 | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207353137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018563019 | ||||||||
FaxNumber: | 3018569370 | ||||||||
Practice Location | |||||||||
Address1: | 10403 HOSPITAL DR STE 103 | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207353149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018568990 | ||||||||
FaxNumber: | 3018568994 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2008 | ||||||||
LastUpdateDate: | 07/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0069138 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1801837786 | 01 | MD | GROUP NPI - CLINTON FAMILY MEDICAL CENTER | OTHER | 1851473722 | 01 | MD | GROUP NPI - MEDICAL AND SURGICAL CLINICS OF SOUTHERN MARYLAND | OTHER |