Provider Demographics
NPI:1891892402
Name:JAVERY, KEITH B (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:B
Last Name:JAVERY
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:710 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2379
Mailing Address - Country:US
Mailing Address - Phone:616-588-7246
Mailing Address - Fax:616-588-7086
Practice Address - Street 1:710 KENMOOR AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2379
Practice Address - Country:US
Practice Address - Phone:616-588-7246
Practice Address - Fax:616-588-7086
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2009-05-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101012927208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164664082Medicaid
MIE83179Medicare UPIN