Provider Demographics
NPI:1043202633
Name:PHILLIPPI, KEITH N (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:N
Last Name:PHILLIPPI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2564
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203
Mailing Address - Country:US
Mailing Address - Phone:478-746-5644
Mailing Address - Fax:478-745-4849
Practice Address - Street 1:380 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-746-5644
Practice Address - Fax:478-745-4849
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036845207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00553517EMedicaid
GA036845OtherGA LICENSE
GA0553517BMedicaid
GA391004OtherWELLCARE
GAP00390637OtherRAILROAD MEDICARE
GA0553517CMedicaid
GA000553517DMedicaid
GA000553517GMedicaid
GA000553517FMedicaid
GA000553517FMedicaid
GA000553517GMedicaid
GA036845OtherGA LICENSE
GAF55633Medicare UPIN
GA05BDCVRMedicare ID - Type UnspecifiedTIFTON ANESTHESIA ASSOC