Provider Demographics
NPI:1285803270
Name:MARTIN, KEITH ALAN (MS, PT)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MS, PT
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Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:6640 PARKDALE PL STE T
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5619
Practice Address - Country:US
Practice Address - Phone:317-808-7070
Practice Address - Fax:317-808-7073
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN05003478A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN255388OtherANTHEM/BCBS
IN218610AMedicare PIN