Provider Demographics
NPI:1891121901
Name:KEEGO FAMILY PRACTICE
Entity Type:Organization
Organization Name:KEEGO FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-977-4516
Mailing Address - Street 1:3435 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KEEGO HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1315
Mailing Address - Country:US
Mailing Address - Phone:248-977-4516
Mailing Address - Fax:248-977-4549
Practice Address - Street 1:3435 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:KEEGO HARBOR
Practice Address - State:MI
Practice Address - Zip Code:48320-1315
Practice Address - Country:US
Practice Address - Phone:248-977-4516
Practice Address - Fax:248-977-4549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069223207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty