Provider Demographics
NPI:1871597419
Name:CROCKER, KEITH THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:THOMAS
Last Name:CROCKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4300 CASCADE RD SE
Mailing Address - Street 2:STE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3631
Mailing Address - Country:US
Mailing Address - Phone:616-245-4513
Mailing Address - Fax:616-245-4802
Practice Address - Street 1:4300 CASCADE RD SE
Practice Address - Street 2:STE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3631
Practice Address - Country:US
Practice Address - Phone:616-245-4513
Practice Address - Fax:616-245-4802
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007635207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP54539OtherBCN
MI1683584Medicaid
MI5413102OtherBCBSM
MIE26227Medicare UPIN
MI5413102Medicare ID - Type Unspecified