Provider Demographics
NPI:1851400410
Name:SIMNICHT, KEITH M (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:M
Last Name:SIMNICHT
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-544-7404
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:50 PARKWAY LN
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3035
Practice Address - Country:US
Practice Address - Phone:601-544-7404
Practice Address - Fax:601-584-6457
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113836Medicaid
MS640507572AZOtherAMERICAN ADMIN GROUP
MS080103890OtherRAILROAD MEDICARE
MS00113836Medicaid
MS640507572AZOtherAMERICAN ADMIN GROUP