Provider Demographics
NPI:1578588679
Name:STEVENS, KEITH M (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:M
Last Name:STEVENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:44199 DEQUINDRE RD
Practice Address - Street 2:SUITE 311
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-964-9490
Practice Address - Fax:248-964-9470
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301009404207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI290F34972OtherBLUE CROSS OF MICHIGAN
MI0E00425OtherBLUE CROSS OF MICHIGAN
MI2693478Medicaid
MIF04801Medicare UPIN
MI0E00425OtherBLUE CROSS OF MICHIGAN