MEDICARE: CHARLES JOSEPH KEITH JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	S0474	TX

General Provider Information

NPI Number	:	1487098240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES JOSEPH KEITH JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 130549
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75713-0549
Country	:	US
Telephone Number	:	903-579-3931
Fax Number	:	903-509-5835

Provider Business Practice Location Address
First Line	:	1100 E LAKE ST STE 150
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-3357
Country	:	US
Telephone Number	:	903-593-0230
Fax Number	:	903-371-7374

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2013
Last Update Date	:	12/31/2019

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