Provider Demographics
NPI:1851308639
Name:JOHNSON, KEITH RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:RUSSELL
Last Name:JOHNSON
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 18824
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27419-8824
Mailing Address - Country:US
Mailing Address - Phone:336-553-1659
Mailing Address - Fax:336-553-3994
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-331-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53765207L00000X
SC29538207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA882501185GMedicaid
GA882501185IMedicaid
GA882501185EMedicaid
GA882501185JMedicaid
GA882501185CMedicaid
GAP00352150OtherRR MEDICARE
GA882501185HMedicaid
GA2500082985OtherCHAMPUS INDIVIDUAL
GA882501185FMedicaid
GA882501185IMedicaid
GAP00352150OtherRR MEDICARE
GAP00352150Medicare PIN