Provider Demographics
NPI:1164423968
Name:HAIRSTON, KEITH A (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:HAIRSTON
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 1:12312 HIGH STAKES DR
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-5772
Mailing Address - Country:US
Mailing Address - Phone:301-838-9606
Mailing Address - Fax:
Practice Address - Street 1:14820 PHYSICIANS LN
Practice Address - Street 2:242
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3945
Practice Address - Country:US
Practice Address - Phone:301-838-9606
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054662207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD085ZMedicare ID - Type Unspecified