Provider Demographics
NPI:1497193957
Name:KEYYAN MEDICAL PLLC
Entity Type:Organization
Organization Name:KEYYAN MEDICAL PLLC
Other - Org Name:ALI MAKKI, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAKKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-908-4255
Mailing Address - Street 1:22239 WEST WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127
Mailing Address - Country:US
Mailing Address - Phone:313-908-4255
Mailing Address - Fax:313-908-4642
Practice Address - Street 1:22239 WEST WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127
Practice Address - Country:US
Practice Address - Phone:313-908-4255
Practice Address - Fax:313-908-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048780207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1114032Medicaid
MIA76154Medicare UPIN
MI1114032Medicaid