Provider Demographics
NPI:1114942273
Name:MCKEOWN, SIMON JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:JOHN
Last Name:MCKEOWN
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:P.O. BOX 478
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265
Mailing Address - Country:US
Mailing Address - Phone:573-581-8127
Mailing Address - Fax:573-582-7053
Practice Address - Street 1:3626 S CLARK ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-4104
Practice Address - Country:US
Practice Address - Phone:573-581-1812
Practice Address - Fax:573-581-1471
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004021597207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205459308Medicaid