Provider Demographics
NPI:1467559476
Name:THORNE, KEITH DEREK (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:DEREK
Last Name:THORNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:501 MARSHALL ST STE 104
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1663
Practice Address - Country:US
Practice Address - Phone:601-969-6404
Practice Address - Fax:601-973-4541
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17941207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09775722Medicaid
MS060000903Medicare UPIN