Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208100000X | Physical Medicine & Rehabilitation Doctor | 044524 | GA |
Y | 2081S0010X | Sports Medicine | 044534 | GA |
Y | 213ES0000X | Sports Medicine | 044534 | GA |
NPI | 1154374312 |
---|---|
Provider Name | Keathern Scott Malone |
First Address | Warner Robins, GA 31093-8536 |
Second Address | Warner Robins, GA 31093-8536 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2006 |
Last Update Date | 13/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000775607E | (05) | GA |
G38809 | (02) |