Healthcare Provider Details

I. General information

NPI: 1912959826
Provider Name (Legal Business Name): FARAD KEITH PRUITT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: FARAD KEITH MUHAMMAD

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-841-1328
  • Fax: 517-841-1320
Mailing address:
  • Phone: 517-841-6913
  • Fax: 517-841-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301074892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: