MEDICARE: DR. GARY J KEOGH MD

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	24656	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051005486	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1790779577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY J KEOGH MD

Provider Business Mailing Address
First Line	:	4619 SPRING HILL AVE
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36608-5709
Country	:	US
Telephone Number	:	251-633-7211
Fax Number	:	251-410-6079

Provider Business Practice Location Address
First Line	:	3715 HIGHWAY 280-431 NORTH
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36867
Country	:	US
Telephone Number	:	251-633-7211
Fax Number	:	251-410-6079

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	09/17/2019

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