Keith A Micetich, MD

Primary specialty

SpecialistTaxonomy code 174400000X

License

26274 Issued in TN

Practice address

72 Physicians Dr
Jackson, TN 38305-2070

Phone

(731) 668-4455

Fax

(731) 668-9007

NPI assigned

Mar 9, 2006

Last updated

Nov 2, 2011By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Womans Clinic a Professional Association

  dba Womans Clinic PA

  • Obstetrics & Gynecology Physician
  • Jackson, TN
  • NPI 1962456574
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1141862400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1320192000000",
    "number": "1427026137",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "72 PHYSICIANS DR",
            "city": "JACKSON",
            "state": "TN",
            "postal_code": "383052070",
            "telephone_number": "731-668-4455",
            "fax_number": "731-664-4508"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "72 PHYSICIANS DR",
            "city": "JACKSON",
            "state": "TN",
            "postal_code": "383052070",
            "telephone_number": "731-668-4455",
            "fax_number": "731-668-9007"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MICETICH",
        "first_name": "KEITH",
        "middle_name": "A",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-09",
        "last_updated": "2011-11-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "TN",
            "license": "26274",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "3009628",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Methodist Healthcare-Memphis Hospitals (Le Bonheur Children's Hospital-Jackson)
• Methodist Le Bonheur Community Outreach
• Barbara Meussner, OT
• Zachary Meyer, MD
• MHC, Inc (Maplewood Health Care Center)
• Michael E Steuer MD PC
• Michael W King, DDS, PLC
• Cameron Michael, DO
• Mid - South Heart Center PC
• Mid South Rehab Outpatient Clinic LLC (360 Total Rehab)

• Specialist in Jackson, TN
• Providers in Jackson, TN by specialty
• Specialist in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.