Provider Demographics
NPI:1447389697
Name:KEITH B. HUCKABY, M.D.
Entity Type:Organization
Organization Name:KEITH B. HUCKABY, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:HUCKABY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:706-647-1752
Mailing Address - Street 1:519 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3504
Mailing Address - Country:US
Mailing Address - Phone:706-647-1752
Mailing Address - Fax:706-647-0339
Practice Address - Street 1:519 W MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3504
Practice Address - Country:US
Practice Address - Phone:706-647-1752
Practice Address - Fax:706-647-0339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00304983AMedicaid
GA00304983AMedicaid
GA10BBCMGMedicare ID - Type Unspecified