Keith Ryan Jackson, M.D.

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

212165 Issued in NY

Practice address

11 Ralph PL
Suite 209
Staten Island, NY 10304-4419

Phone

(718) 727-1331

Fax

(718) 727-2159

NPI assigned

Oct 10, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Dermatology

Education

State University of New York Downstate Medical Center, 1997

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Hospital & facility affiliations

• Mountain Lakes Medical Center Hospital, Clayton, GA, CCN 111336

Merit-based Incentive Payment System (MIPS)

Final score

85.03 of 100Reported as individual

Quality

72.78

Promoting interoperability

100

Improvement activities

40

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Keith Ryan Jackson MD PC

  • Dermatology Physician
  • Staten Island, NY
  • NPI 1326216847
  Medicare reassignment NPD Authorized official
• Atlantic Dermatologic Associates, LLP

  • Specialist
  • Lynbrook, NY
  • NPI 1447264387
  NPD (past)
• Modern Family Health NP PLLC

  • Multi-Specialty Clinic/Center
  • Staten Island, NY
  • NPI 1346131257
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Professional Resources Management of Rabun, LLC

  • Critical Access Hospital
  • Clayton, GA
  • NPI 1326191180
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160438400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1369699200000",
    "number": "1124116041",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 RALPH PL",
            "address_2": "SUITE 209",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103044419",
            "telephone_number": "718-727-1331",
            "fax_number": "718-727-2159"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 RALPH PL",
            "address_2": "SUITE 209",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103044419",
            "telephone_number": "718-727-1331",
            "fax_number": "718-727-2159"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KEITH",
        "middle_name": "RYAN",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-10-10",
        "last_updated": "2013-05-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NY",
            "license": "212165",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02239307",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jack Miceli DDS PC
• Ann M Jackman, D.D.S.
• Brandon Joshua Jackson, D.D.S
• Dana Jackson, M.S.
• Jill Jackson, LPN
• Kelly A Jackson, OTR/L
• Rebecca Sabrina Jackson, CRPA
• Sharon Jackson
• Starr Shalae Jackson
• Jaclyn Hunt

• Dermatology Physician in Staten Island, NY
• Providers in Staten Island, NY by specialty
• Dermatology Physician in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 28, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.