Provider Demographics
NPI:1659690881
Name:KETCHUM, GEORGIA LEE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:LEE
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2191 E JOHNSON AVE
Mailing Address - Street 2:INPATIENT PSYCHIATRY
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6029
Mailing Address - Country:US
Mailing Address - Phone:850-494-3953
Mailing Address - Fax:850-494-3960
Practice Address - Street 1:2191 E JOHNSON AVE
Practice Address - Street 2:INPATIENT PSYCHIATRY
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6029
Practice Address - Country:US
Practice Address - Phone:850-494-3953
Practice Address - Fax:850-494-3960
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1201472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry