Healthcare Provider Details

I. General information

NPI: 1366827982
Provider Name (Legal Business Name): KEITH DAVIDSON NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2433 BLACK RIVER ST
DECKERVILLE MI
48427-9425
US

IV. Provider business mailing address

PO BOX 126 3532 MAIN STREET
DECKERVILLE MI
48427-0126
US

V. Phone/Fax

Practice location:
  • Phone: 810-376-2885
  • Fax:
Mailing address:
  • Phone: 810-376-3100
  • Fax: 810-376-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704274292
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: