Healthcare Provider Details

I. General information

NPI: 1093758435
Provider Name (Legal Business Name): JOHN T KEANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16105 S LA GRANGE RD
ORLAND PARK IL
60467-5503
US

IV. Provider business mailing address

16105 S LA GRANGE RD
ORLAND PARK IL
60467-5503
US

V. Phone/Fax

Practice location:
  • Phone: 708-636-3767
  • Fax: 708-636-4361
Mailing address:
  • Phone: 708-636-3767
  • Fax: 708-636-4361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number036-049226
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036-049226
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: