Provider Demographics
NPI:1568449536
Name:KEADY, JR, DWIGHT S (MD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:S
Last Name:KEADY, JR
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 1:213 EAST HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350
Mailing Address - Country:US
Mailing Address - Phone:601-656-6116
Mailing Address - Fax:601-781-2363
Practice Address - Street 1:213 EAST HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350
Practice Address - Country:US
Practice Address - Phone:601-656-6116
Practice Address - Fax:601-781-2363
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10775174400000X
MS131005207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS830005996OtherPALMETTO GBA RAILROAD
MSCF9149OtherRAILROAD GROUP #
MS00121130Medicaid
MSB66170Medicare UPIN
MSCF9149OtherRAILROAD GROUP #
MSCF9149OtherRAILROAD GROUP #