Individual
DR. KEITH A MICETICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
72 PHYSICIANS DR, JACKSON, TN 38305-2070
(731) 668-4455
(731) 668-9007
Mailing address
72 PHYSICIANS DR, JACKSON, TN 38305-2070
(731) 668-4455
(731) 664-4508
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
26274
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3009628
BLUE CROSS BLUE SHIELD
TN
Enumeration date
03/09/2006
Last updated
11/02/2011
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