Provider Demographics
NPI:1093758435
Name:KEANE, JOHN T (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:KEANE
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 1:16105 S LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5503
Mailing Address - Country:US
Mailing Address - Phone:708-636-3767
Mailing Address - Fax:708-636-4361
Practice Address - Street 1:16105 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5503
Practice Address - Country:US
Practice Address - Phone:708-636-3767
Practice Address - Fax:708-636-4361
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-049226207ND0900X, 207N00000X
IL207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK28341Medicare ID - Type Unspecified
ILD12971Medicare UPIN