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NPI Code Detail

MEDICARE: MR. PHILIP ANTHONY KEITH ATC

MEDICARE: MR. PHILIP ANTHONY KEITH ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer

General Provider Information

NPI Number : 1578593711
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. PHILIP ANTHONY KEITH ATC
Provider Business Mailing Address
First Line : 23 N LINCOLN ST
Second Line :
City : ROCKFORD
State : MI
Zip : 49341-1311
Country : US
Telephone Number : 616-863-0957
Fax Number : 616-222-1542
Provider Business Practice Location Address
First Line : 1001 E BELTLINE AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49525-5803
Country : US
Telephone Number : 616-831-7006
Fax Number : 616-222-1542
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/04/2006
Last Update Date : 07/08/2007

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