Healthcare Provider Details

I. General information

NPI: 1427026137
Provider Name (Legal Business Name): KEITH A MICETICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 PHYSICIANS DR
JACKSON TN
38305-2070
US

IV. Provider business mailing address

72 PHYSICIANS DR
JACKSON TN
38305-2070
US

V. Phone/Fax

Practice location:
  • Phone: 731-668-4455
  • Fax: 731-668-9007
Mailing address:
  • Phone: 731-668-4455
  • Fax: 731-664-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number26274
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: