Provider Demographics
NPI:1427026137
Name:MICETICH, KEITH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:MICETICH
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 1:72 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2070
Mailing Address - Country:US
Mailing Address - Phone:731-668-4455
Mailing Address - Fax:731-664-4508
Practice Address - Street 1:72 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2070
Practice Address - Country:US
Practice Address - Phone:731-668-4455
Practice Address - Fax:731-668-9007
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26274174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3009628OtherBLUE CROSS BLUE SHIELD
TNG16712Medicare UPIN
TN3009628OtherBLUE CROSS BLUE SHIELD