MEDICARE: MICHAEL D KEOWN CO, LPO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Z00000X	Orthotist	1373	TX
2	224P00000X	Prosthetist	1373	TX

General Provider Information

NPI Number	:	1255562294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D KEOWN CO, LPO

Provider Business Mailing Address
First Line	:	2413 E 5TH ST
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-3523
Country	:	US
Telephone Number	:	903-533-8202
Fax Number	:	903-533-8611

Provider Business Practice Location Address
First Line	:	2413 E 5TH ST
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-3523
Country	:	US
Telephone Number	:	903-533-8202
Fax Number	:	903-533-8611

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	08/06/2009

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