Provider Demographics
NPI:1003000308
Name:KEITH M DOCKERY, MD PC
Entity Type:Organization
Organization Name:KEITH M DOCKERY, MD PC
Other - Org Name:BUCKHEAD EAR, NOSE AND THROAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:PARKS
Authorized Official - Last Name:DILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-350-7966
Mailing Address - Street 1:1800 PEACHTREE ST NW
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2519
Mailing Address - Country:US
Mailing Address - Phone:404-350-7966
Mailing Address - Fax:404-350-7968
Practice Address - Street 1:1800 PEACHTREE ST NW
Practice Address - Street 2:SUITE 700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2519
Practice Address - Country:US
Practice Address - Phone:404-350-7966
Practice Address - Fax:404-350-7968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003711231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA443781AMedicaid
GA443781AMedicaid