Provider Demographics
NPI:1346402153
Name:KEITH, PHILIP DAVID (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:DAVID
Last Name:KEITH
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 1:3001 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4007
Mailing Address - Country:US
Mailing Address - Phone:336-765-0383
Mailing Address - Fax:336-201-0999
Practice Address - Street 1:3001 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4007
Practice Address - Country:US
Practice Address - Phone:336-765-0383
Practice Address - Fax:336-201-0999
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01207207R00000X, 207RC0200X
SC30827207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC308278Medicaid
SCAA67947951Medicare PIN