MEDICARE: KATHLEEN KEITHLEY 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	2003029518	MO
2	363AM0700X	Medical Physician Assistant	085-002555	IL

General Provider Information

NPI Number	:	1760457352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN KEITHLEY PA-C

Provider Business Mailing Address
First Line	:	340 W LINCOLN ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-1900
Country	:	US
Telephone Number	:	618-233-6044
Fax Number	:	618-233-3287

Provider Business Practice Location Address
First Line	:	340 W LINCOLN ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-1900
Country	:	US
Telephone Number	:	618-233-6044
Fax Number	:	618-233-3287

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	11/05/2007

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