Provider Demographics
NPI:1609850130
Name:TOM, KEITH B (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:B
Last Name:TOM
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 1:49221 VAN DYKE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1336
Mailing Address - Country:US
Mailing Address - Phone:586-254-4860
Mailing Address - Fax:586-254-5844
Practice Address - Street 1:49221 VAN DYKE
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48317-1336
Practice Address - Country:US
Practice Address - Phone:586-254-4860
Practice Address - Fax:586-254-5844
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2646558Medicaid
0P04980Medicare ID - Type Unspecified
A77750Medicare UPIN