Provider Demographics
NPI:1467577221
Name:GORNY, KEITH JEROME (PA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:JEROME
Last Name:GORNY
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Gender:M
Credentials:PA
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Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1865
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:44201 DEQUINDRE RD STE EC
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-5111
Practice Address - Fax:248-964-5068
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2022-07-25
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Provider Licenses
StateLicense IDTaxonomies
MI5601004350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant