MEDICARE: ERIN JEAN KEECH PA-C

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	363AM0700X	Medical Physician Assistant	085.002860	IL
2	363A00000X	Physician Assistant	12422	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	085.002860	OTHER	IL	STATE LICENSE NO.
2	12422	OTHER	MN	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1700906088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN JEAN KEECH PA-C

Provider Business Mailing Address
First Line	:	800 BIESTERFIELD RD
Second Line	:	SUITE # 106
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3372
Country	:	US
Telephone Number	:	847-981-8866
Fax Number	:	847-981-5580

Provider Business Practice Location Address
First Line	:	1457 WHITE OAK DR
Second Line	:
City	:	CHASKA
State	:	MN
Zip	:	55318-2525
Country	:	US
Telephone Number	:	952-368-3800
Fax Number	:

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

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	10/31/2018

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