Healthcare Provider Details

I. General information

NPI: 1760573695
Provider Name (Legal Business Name): KEITH DANIEL ROSOL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

PO BOX 5329
SAGINAW MI
48603-0329
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-6700
  • Fax: 616-364-4960
Mailing address:
  • Phone: 616-364-6700
  • Fax: 989-401-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301064028
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: