MEDICARE: MARK K KEOHANE M.D.

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	207X00000X	Orthopaedic Surgery Physician	34653	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	4061116	OTHER	AETNA
2	43177	OTHER	CMR
3	18883	OTHER	BLUE CROSS BLUE SHIELD
4	122683	OTHER	HEALTHLINK
5	351240001	OTHER	CIGNA DMERC
6	900094	OTHER	UHC
7	4434V6097	OTHER	HEALTHCARE USA
8	9043	OTHER	EXCLUSIVE CHOICE
9	2253V3458	OTHER	GHP/ADVANTRA
10	SP10133	OTHER	CIGNA

General Provider Information

NPI Number	:	1710980750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK K KEOHANE M.D.

Provider Business Mailing Address
First Line	:	9323 PHOENIX VILLAGE PKWY
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-4281
Country	:	US
Telephone Number	:	636-561-5030
Fax Number	:	636-561-5033

Provider Business Practice Location Address
First Line	:	9323 PHOENIX VILLAGE PKWY
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-4281
Country	:	US
Telephone Number	:	636-561-5030
Fax Number	:	636-561-5033

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	03/01/2012

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Directions to “ MARK K KEOHANE M.D.” Practice Location

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