Provider Demographics
NPI:1801084629
Name:KEITH C MCKENZIE MD PLLC
Entity type:Organization
Organization Name:KEITH C MCKENZIE MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-286-9720
Mailing Address - Street 1:15501 METROPOLITAN PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1684
Mailing Address - Country:US
Mailing Address - Phone:586-286-9720
Mailing Address - Fax:586-286-3134
Practice Address - Street 1:15501 METROPOLITAN PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-1684
Practice Address - Country:US
Practice Address - Phone:586-286-9720
Practice Address - Fax:586-286-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067883207Q00000X
MI5601002587363AM0700X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E02201OtherBLUE CROSS BLUE SHIELD
MI0P03910Medicare PIN
MI0P04100Medicare PIN
0P03910Medicare PIN