Basic Information
| Provider Information | |||||||||
| NPI: | 1477563229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCMANUS | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 269 GILLMAN RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280377923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043164930 | ||||||||
| FaxNumber: | 7043164931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32789 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 56872 | 01 | NC | BCBS OF NC | OTHER | 8957844 | 05 | NC | MEDICAID |