Provider Demographics
NPI:1326216847
Name:KEITH RYAN JACKSON MD PC
Entity Type:Organization
Organization Name:KEITH RYAN JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-727-1331
Mailing Address - Street 1:11 RALPH PL
Mailing Address - Street 2:SUITE 209
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4419
Mailing Address - Country:US
Mailing Address - Phone:718-727-1331
Mailing Address - Fax:718-727-2159
Practice Address - Street 1:11 RALPH PL
Practice Address - Street 2:SUITE 209
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4419
Practice Address - Country:US
Practice Address - Phone:718-727-1331
Practice Address - Fax:718-727-2159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212165207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02239307Medicaid
NY02239307Medicaid
NYW31031Medicare PIN