MEDICARE: DR. GARY M KEOLEIAN M.D.

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	207W00000X	Ophthalmology Physician	GK407137	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538163217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY M KEOLEIAN M.D.

Provider Business Mailing Address
First Line	:	536 HANNA ST
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-1616
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4499 TOWN CENTER PKWY
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48532-3425
Country	:	US
Telephone Number	:	810-733-7111
Fax Number	:	810-733-7141

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	02/10/2012

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