Healthcare Provider Details

I. General information

NPI: 1710980750
Provider Name (Legal Business Name): MARK K KEOHANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9323 PHOENIX VILLAGE PKWY
O FALLON MO
63366-4281
US

IV. Provider business mailing address

9323 PHOENIX VILLAGE PKWY
O FALLON MO
63366-4281
US

V. Phone/Fax

Practice location:
  • Phone: 636-561-5030
  • Fax: 636-561-5033
Mailing address:
  • Phone: 636-561-5030
  • Fax: 636-561-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34653
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: