Provider Demographics
NPI:1750393203
Name:KEITH, JACK P (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:KEITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1823
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1823
Mailing Address - Country:US
Mailing Address - Phone:207-755-3715
Mailing Address - Fax:207-755-3728
Practice Address - Street 1:45 GOLDER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6033
Practice Address - Country:US
Practice Address - Phone:207-755-3715
Practice Address - Fax:207-755-3728
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME013034207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050029135OtherRAILROAD MEDICARE
ME002622OtherANTHEM BC/BS
ME316040099Medicaid
ME316040099Medicaid
050029135OtherRAILROAD MEDICARE