Provider Demographics
NPI:1629053822
Name:HART, KEITH M (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:M
Last Name:HART
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 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-6760
Mailing Address - Fax:864-224-3773
Practice Address - Street 1:2000 E GREENVILLE ST
Practice Address - Street 2:STE 3000
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-512-6760
Practice Address - Fax:864-224-3773
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12019208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5476Medicaid
GA000400265CMedicaid
SC120194Medicaid
D83268Medicare UPIN