Provider Demographics
NPI:1740437052
Name:SANTIAGO, KEITH JOHN (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:JOHN
Last Name:SANTIAGO
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 1:2880 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9171
Mailing Address - Country:US
Mailing Address - Phone:843-797-5050
Mailing Address - Fax:843-797-3633
Practice Address - Street 1:2880 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9171
Practice Address - Country:US
Practice Address - Phone:843-797-5050
Practice Address - Fax:843-797-3633
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32526207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20076508OtherSELECT HEALTH DME
SC1326287434OtherMEDICAID DME NPI
SCD043OtherMEDICARE GROUP PTAN
SCDU4331OtherRAILROAD MEDICARE GROUP PTAN
SC32526OtherCURRENT STATE MEDICAL LICENSE
SC325269Medicaid
SCGP6337OtherMEDICAID GROUP
SCP01283675OtherRAILROAD MEDICARE PTAN
SC32526OtherCURRENT STATE MEDICAL LICENSE
SC325269Medicaid
SCGP6337OtherMEDICAID GROUP
SCPA0971OtherMEDICAID GROUP
SC57-0634057OtherGROUP TAX ID
SCD043OtherMEDICARE GROUP PTAN
SC1701OtherMEDICARE GROUP
SC0422990001Medicare NSC