Provider Demographics
NPI:1053577742
Name:THATCH, KEITH ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ANDREW
Last Name:THATCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 5TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4804
Mailing Address - Country:US
Mailing Address - Phone:727-767-4170
Mailing Address - Fax:
Practice Address - Street 1:601 5TH ST S STE 306
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4804
Practice Address - Country:US
Practice Address - Phone:727-767-3439
Practice Address - Fax:727-767-4346
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-157202086S0120X
VA01012805912086S0120X
FLME1346482086S0120X
MI43010991652086S0102X
PAMD4329702086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023296400Medicaid