Provider Demographics
NPI:1851380497
Name:KEITH, CAROLYN J (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:KEITH
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-935-5770
Mailing Address - Fax:231-935-0747
Practice Address - Street 1:4100 PARK FOREST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7331
Practice Address - Country:US
Practice Address - Phone:231-935-5770
Practice Address - Fax:231-935-0747
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2015-04-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301048726207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1851380497Medicaid
MI1851380497Medicaid
0B86015 001Medicare PIN