Provider Demographics
NPI:1295870582
Name:DRS KETAI P C
Entity type:Organization
Organization Name:DRS KETAI P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KETAI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-855-2220
Mailing Address - Street 1:31390 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2561
Mailing Address - Country:US
Mailing Address - Phone:248-855-2220
Mailing Address - Fax:248-855-1068
Practice Address - Street 1:31390 NORTHWESTERN HWY
Practice Address - Street 2:SUITE E
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2561
Practice Address - Country:US
Practice Address - Phone:248-855-2220
Practice Address - Fax:248-855-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRK000588213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F3632384812OtherMEDICARE PPI
MI80721OtherOMNICARE POS
MIP76006OtherBCN
MI540F340180OtherBCBSM DME
MI5635300OtherBLUE CROSSBLUE SHIELD
MI101877Medicaid
MI20721OtherOMNICARE HMO
MI20721OtherOMNICARE HMO
MI80721OtherOMNICARE POS
MI0F36323Medicare PIN