Basic Information
| Provider Information | |||||||||
| NPI: | 1104806116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9045 US HIGHWAY 31 | ||||||||
| Address2: | |||||||||
| City: | BERRIEN SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694732222 | ||||||||
| FaxNumber: | 2694736880 | ||||||||
| Practice Location | |||||||||
| Address1: | 9045 US HIGHWAY 31 | ||||||||
| Address2: | |||||||||
| City: | BERRIEN SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694732222 | ||||||||
| FaxNumber: | 2694736880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301081055 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 4301081055 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1902086689 | 01 | MI | GROUP NPI | OTHER | P17270001 | 01 | MI | MEDICARE INDIVIDUAL PTAN | OTHER | 104694670 | 05 | MI | MEDICAID | 700A146860 | 01 | MI | BCBSM GROUP PIN | OTHER |