Provider Demographics
NPI:1760573695
Name:ROSOL, KEITH DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:DANIEL
Last Name:ROSOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5329
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-0329
Mailing Address - Country:US
Mailing Address - Phone:616-364-6700
Mailing Address - Fax:989-401-4235
Practice Address - Street 1:200 JEFFERSON SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-364-6700
Practice Address - Fax:616-364-4960
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010640282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4102564100Medicaid
MI300103083OtherRR MEDICARE
G81179Medicare UPIN