Basic Information
| Provider Information | |||||||||
| NPI: | 1407890510 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEORGESON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 8TH AVE | ||||||||
| Address2: | SUITE 100 L-1 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094745445 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 11841 | AL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0120X | MD60183442 | WA | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000014166 | 05 | AL | MEDICAID | 051523114 | 01 | AL | BLUE CROSS | OTHER | 009961775 | 05 | AL | MEDICAID | 000014166 | 01 | AL | BLUE CROSS | OTHER | 009946695 | 05 | AL | MEDICAID | 051520177 | 01 | AL | BLUE CROSS | OTHER | 37862742A | 01 | GA | GEORGIA MEDICAID | OTHER | A40463 | 01 | AL | HEALTHSPRING OF ALABAMA | OTHER | A40463 | 01 | AL | VIVA | OTHER | 00122960 | 01 | MS | MISSISSIPPI MEDICAID | OTHER |