Provider Demographics
NPI:1104962703
Name:LONERGAN, KEITH THOMAS (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:THOMAS
Last Name:LONERGAN
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:315 MEDICAL PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2456
Practice Address - Country:US
Practice Address - Phone:864-454-7422
Practice Address - Fax:864-797-9701
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30396207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG51248Medicaid
SCP00607534OtherRR MEDICARE
SC576007863179OtherBCBS
SCAA23077951Medicare PIN
SCG51248Medicaid