Provider Demographics
NPI:1043552227
Name:CORPUS, KEITH THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:THOMAS
Last Name:CORPUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N WILLIAM KUMPF BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2507
Mailing Address - Country:US
Mailing Address - Phone:309-676-5546
Mailing Address - Fax:
Practice Address - Street 1:303 N WILLIAM KUMPF BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605
Practice Address - Country:US
Practice Address - Phone:309-676-5546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.148410207XX0005X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1043552227Medicaid
NCNC3378Medicaid
NC0397730007OtherNSC #