Healthcare Provider Details

I. General information

NPI: 1801830757
Provider Name (Legal Business Name): KEITH CRESWELL MCKENZIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15501 METROPOLITAN PKWY STE 110
CLINTON TWP MI
48036-1684
US

IV. Provider business mailing address

15501 METROPOLITAN PKWY STE 110
CLINTON TWP MI
48036-1684
US

V. Phone/Fax

Practice location:
  • Phone: 586-286-9720
  • Fax: 586-286-3134
Mailing address:
  • Phone: 586-286-9720
  • Fax: 586-286-3134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301067883
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: