Provider Demographics
NPI:1538136718
Name:BAILEY, KEITH DALE (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DALE
Last Name:BAILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3731
Mailing Address - Country:US
Mailing Address - Phone:269-373-7488
Mailing Address - Fax:269-373-0123
Practice Address - Street 1:200 N PARK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3731
Practice Address - Country:US
Practice Address - Phone:269-373-7488
Practice Address - Fax:269-373-0123
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041932207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110102734OtherMEDICARE ID TYPE UNSPECIF
MI11-0390150-1OtherBCBS
MI1338976Medicaid
MI1447261730OtherBCBSM - WMCC
MI1538136718Medicaid
MIB49222Medicare UPIN
MI1538136718Medicaid
MI11-0390150-1OtherBCBS