Provider Demographics
NPI:1922090224
Name:HARRIS, KEITH R (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:HARRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:103 JOHN MADDOX DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1419
Mailing Address - Country:US
Mailing Address - Phone:706-235-7711
Mailing Address - Fax:706-235-9944
Practice Address - Street 1:100 MARKET PLACE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-8717
Practice Address - Country:US
Practice Address - Phone:470-490-9600
Practice Address - Fax:470-447-1815
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2020-10-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA050930174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF80810Medicare UPIN
GA07BBSKVMedicare ID - Type Unspecified