Provider Demographics
NPI:1770686776
Name:SILLIMAN, KEITH CANFIELD (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:CANFIELD
Last Name:SILLIMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 BLUE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35226-3133
Mailing Address - Country:US
Mailing Address - Phone:205-979-6152
Mailing Address - Fax:
Practice Address - Street 1:2870 OLD ROCKY RIDGE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-2927
Practice Address - Country:US
Practice Address - Phone:205-824-1257
Practice Address - Fax:205-824-3629
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-928-TA-495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51060858OtherBLUE CROSS BLUE SHIELD
ALU77719Medicare UPIN
AL51060858OtherBLUE CROSS BLUE SHIELD