Healthcare Provider Details

I. General information

NPI: 1043574874
Provider Name (Legal Business Name): ANDREW JOHN KETNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 HIGHLAND RD STE 101
WATERFORD MI
48328-2163
US

IV. Provider business mailing address

4000 HIGHLAND RD STE 101
WATERFORD MI
48328-2163
US

V. Phone/Fax

Practice location:
  • Phone: 248-270-5622
  • Fax: 248-856-2474
Mailing address:
  • Phone: 248-270-5622
  • Fax: 248-856-2474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5101019855
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: