Provider Demographics
NPI:1972651859
Name:BUCKLEY, KEITH D (CRNA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:CRNA
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 934369
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-0001
Mailing Address - Country:US
Mailing Address - Phone:800-897-6169
Mailing Address - Fax:800-897-6170
Practice Address - Street 1:5 MOBILE INFIRMARY CIR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3513
Practice Address - Country:US
Practice Address - Phone:251-432-4497
Practice Address - Fax:251-432-0577
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-088997207L00000X
AL1088997367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051539202OtherBC OF AL
AL009941427Medicaid
AL009941428Medicaid
AL009941431Medicaid
AL051539203OtherBC OF AL
AL051539204OtherBC OF AL
AL009941429Medicaid