Provider Demographics
NPI:1316062342
Name:KEITH, MARK ABRAHAM
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ABRAHAM
Last Name:KEITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3696
Practice Address - Street 1:4907 BOONE TRAIL ROAD
Practice Address - Street 2:INDEPENDENCE UNLIMITED
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:28244
Practice Address - Country:US
Practice Address - Phone:276-431-4473
Practice Address - Fax:276-431-4484
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other