Provider Demographics
NPI:1154388734
Name:KEENUM, AMY JANE (DO, PHARMD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JANE
Last Name:KEENUM
Suffix:
Gender:F
Credentials:DO, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:A235
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-355-1300
Mailing Address - Fax:517-355-1710
Practice Address - Street 1:804 SERVICE RD
Practice Address - Street 2:A235
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7015
Practice Address - Country:US
Practice Address - Phone:517-355-1300
Practice Address - Fax:517-355-1710
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101011498207Q00000X
NC9500113207Q00000X
TNDO1349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154388734Medicaid
TN3306480Medicaid
TN01-41688OtherUNITED HEALTH CARE
TN100032496OtherPHP TENNCARE
TN9206416OtherCIGNA
TNTN01G4OtherJOHN DEERE
080164595OtherRAILROAD MEDICARE
TN3159480OtherBLUE CROSS/BLUE SHIELD
TN5954498OtherAETNA
TN3159480OtherBLUE CROSS/BLUE SHIELD
3306480Medicare ID - Type Unspecified
TNTN01G4OtherJOHN DEERE