Provider Demographics
NPI:1295987030
Name:KEITH P HUSSEY MD PA
Entity type:Organization
Organization Name:KEITH P HUSSEY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:P
Authorized Official - Last Name:HUSSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-643-9767
Mailing Address - Street 1:681 GOODLETTE RD N
Mailing Address - Street 2:SUITE 130
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5458
Mailing Address - Country:US
Mailing Address - Phone:239-643-9767
Mailing Address - Fax:239-649-5878
Practice Address - Street 1:681 GOODLETTE RD N
Practice Address - Street 2:SUITE 130
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5458
Practice Address - Country:US
Practice Address - Phone:239-643-9767
Practice Address - Fax:239-649-5878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46740207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049444500Medicaid
FL100010818OtherRAILROAD MEDICARE
FL049444500Medicaid
FL100010818OtherRAILROAD MEDICARE