Provider Demographics
NPI:1124180674
Name:KEITH, JEANETTE N (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:N
Last Name:KEITH
Suffix:
Gender:F
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 2239
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35609-2239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 SOMERVILLE RD SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4335
Practice Address - Country:US
Practice Address - Phone:256-973-2700
Practice Address - Fax:256-686-3342
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098638207RG0100X
AL27942207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098638Medicaid
AL147364Medicaid
L68331Medicare ID - Type Unspecified
IL036098638Medicaid