Healthcare Provider Details

I. General information

NPI: 1790670958
Provider Name (Legal Business Name): KETNER ORTHOPEDICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2025
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 Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREW JOHN KETNER
Title or Position: OWNER
Credential: DO
Phone: 248-270-5622