Provider Demographics
NPI:1548229644
Name:WHITESIDES, KEITH RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:RANDALL
Last Name:WHITESIDES
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:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:2800 FERRY ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3022
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-447-9749
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032200A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN431714OtherPHCS PID NUMBER
IN000000190237OtherANTHEM PROVIDER NUMBER
IN10826183OtherCAQH NUMBER
IN200100480Medicaid
IN080135078Medicare PIN
IN431714OtherPHCS PID NUMBER
IN199190RMedicare PIN
INE28536Medicare UPIN
IN815500O4Medicare PIN