Provider Demographics
NPI:1699841304
Name:KEEBY, RENA L (PAC)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:L
Last Name:KEEBY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-9775
Mailing Address - Country:US
Mailing Address - Phone:404-364-7000
Mailing Address - Fax:404-364-4732
Practice Address - Street 1:2470 MOUNT ZION PARKWAY
Practice Address - Street 2:DEPARTMENT OF DERMATOLOGY
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:770-603-3649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002657207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
97WCGHNMedicare ID - Type Unspecified
Q36886Medicare UPIN