Basic Information
| Provider Information | |||||||||
| NPI: | 1538136718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | DALE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 N PARK ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490073731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693737488 | ||||||||
| FaxNumber: | 2693730123 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 N PARK ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490073731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693737488 | ||||||||
| FaxNumber: | 2693730123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 10/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 4301041932 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RX0202X | 4301041932 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 110102734 | 01 | MI | MEDICARE ID TYPE UNSPECIF | OTHER | 11-0390150-1 | 01 | MI | BCBS | OTHER | 1338976 | 05 | MI | MEDICAID | 1447261730 | 01 | MI | BCBSM - WMCC | OTHER | 1538136718 | 05 | MI | MEDICAID |