Provider Demographics
NPI:1689866121
Name:KEITH G VANDERZYL JR MD PA
Entity Type:Organization
Organization Name:KEITH G VANDERZYL JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:VANDERZYL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:334-774-5501
Mailing Address - Street 1:218 HOSPITAL AVE
Mailing Address - Street 2:STE D
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-2064
Mailing Address - Country:US
Mailing Address - Phone:334-774-5501
Mailing Address - Fax:334-445-9785
Practice Address - Street 1:218 HOSPITAL AVE
Practice Address - Street 2:STE D
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-2064
Practice Address - Country:US
Practice Address - Phone:334-774-5501
Practice Address - Fax:334-445-9785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8612174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000011034Medicaid
000011034OtherBCBS
AL0196890002OtherDMERC
000011034OtherBCBS
AL0196890002OtherDMERC