Basic Information
| Provider Information | |||||||||
| NPI: | 1851308639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18824 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274198824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 DARLING AVE | ||||||||
| Address2: | DEPT OF ANESTHESIA | ||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315015246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123386511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 053765 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 29538 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 882501185F | 05 | GA | MEDICAID | 882501185I | 05 | GA | MEDICAID | 882501185G | 05 | GA | MEDICAID | 882501185J | 05 | GA | MEDICAID | P00352150 | 01 | GA | RR MEDICARE | OTHER | 2500082985 | 01 | GA | CHAMPUS INDIVIDUAL | OTHER | 882501185E | 05 | GA | MEDICAID | 882501185H | 05 | GA | MEDICAID | 882501185C | 05 | GA | MEDICAID |