Provider Demographics
NPI:1154374312
Name:MALONE, KEATHERN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:KEATHERN
Middle Name:SCOTT
Last Name:MALONE
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 1:3051 WATSON BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-8536
Mailing Address - Country:US
Mailing Address - Phone:478-971-2227
Mailing Address - Fax:478-953-4677
Practice Address - Street 1:3051 WATSON BLVD
Practice Address - Street 2:SUITE400
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8536
Practice Address - Country:US
Practice Address - Phone:478-953-4563
Practice Address - Fax:478-953-4616
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044524208100000X
GA0445342081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000775607EMedicaid
GA000775607EMedicaid
GA20BBFFGMedicare ID - Type Unspecified