MEDICARE: KEITH M. MONSON, M.D., SC

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	208600000X	Surgery Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4632066	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1265539472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEITH M. MONSON, M.D., SC

Provider Business Mailing Address
First Line	:	P.O. BOX 1756
Second Line	:
City	:	KANKAKEE
State	:	IL
Zip	:	60901-1756
Country	:	US
Telephone Number	:	815-932-6400
Fax Number	:	815-935-7062

Provider Business Practice Location Address
First Line	:	400 N WALL ST
Second Line	:	SUITE 304
City	:	KANKAKEE
State	:	IL
Zip	:	60901-2940
Country	:	US
Telephone Number	:	815-932-6400
Fax Number	:	815-935-7062

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEITH M. MONSON
Credential	:	M.D.
Telephone Number	:	815-932-6400

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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