MEDICARE: DR. KEITH A MICETICH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	26274	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3009628	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1427026137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH A MICETICH MD

Provider Business Mailing Address
First Line	:	72 PHYSICIANS DR
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2070
Country	:	US
Telephone Number	:	731-668-4455
Fax Number	:	731-664-4508

Provider Business Practice Location Address
First Line	:	72 PHYSICIANS DR
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-2070
Country	:	US
Telephone Number	:	731-668-4455
Fax Number	:	731-668-9007

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	11/02/2011

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Directions to “ DR. KEITH A MICETICH MD” Practice Location

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