Healthcare Provider Details

I. General information

NPI: 1134653520
Provider Name (Legal Business Name): IAN RANDALL KECK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 04/20/2024
Certification Date: 04/20/2024
Deactivation Date: 06/18/2019
Reactivation Date: 06/21/2019

III. Provider practice location address

407 ULUNIU ST
KAILUA HI
96734-2519
US

IV. Provider business mailing address

1000 HOUGHTON AVENUE
SAGINAW MI
48602
US

V. Phone/Fax

Practice location:
  • Phone: 808-261-3326
  • Fax:
Mailing address:
  • Phone: 989-583-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDOS-2295
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: