Provider Demographics
NPI:1578655049
Name:MARSHALL, KEITH N (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:N
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3272 E. 12 MILE ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092
Mailing Address - Country:US
Mailing Address - Phone:586-558-9360
Mailing Address - Fax:586-573-3130
Practice Address - Street 1:3272 E. 12 MILE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-558-9360
Practice Address - Fax:586-573-3130
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKM007974208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4508283Medicaid
MI0N6800Medicare ID - Type Unspecified
MI4508283Medicaid