Provider Demographics
NPI:1316164288
Name:KEELEY, JOHN STEWART JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:STEWART
Last Name:KEELEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:STEWART
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR STE 6A
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3256
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:3647 J DEWEY GRAY CIR STE 200
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2205
Practice Address - Country:US
Practice Address - Phone:706-504-9712
Practice Address - Fax:706-504-9703
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN49812208600000X, 2086S0102X
GA68360208600000X, 2086S0102X
MEMD278942086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I028054Medicare PIN