Provider Demographics
NPI:1811001167
Name:NELSON, KEITH G (DO)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:NELSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:A201
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:463 E CIRCLE DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7500
Practice Address - Country:US
Practice Address - Phone:517-884-6546
Practice Address - Fax:517-432-9460
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101010456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4756782Medicaid
MI5330084OtherBLUE CARE NETWORK
MI1811001167Medicaid
MI0100197OtherPHP
MI0100197OtherPHP
MIP19420001Medicare ID - Type Unspecified