=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790670958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KETNER ORTHOPEDICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2025
-----------------------------------------------------
Last Update Date | 11/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 HIGHLAND RD STE 101
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-2163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-270-5622
-----------------------------------------------------
Fax | 248-856-2474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 HIGHLAND RD STE 101
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-2163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-270-5622
-----------------------------------------------------
Fax | 248-856-2474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREW JOHN KETNER
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 248-270-5622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------