Healthcare Provider Details

I. General information

NPI: 1831578293
Provider Name (Legal Business Name): ANDREW KETO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

IV. Provider business mailing address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036147094
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.066384
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: