Provider Demographics
NPI:1184679409
Name:THOMAE, KEITH R (MD)
Entity Type:Individual
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First Name:KEITH
Middle Name:R
Last Name:THOMAE
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3331 W DEYOUNG ST
Mailing Address - Street 2:STE 305
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5898
Mailing Address - Country:US
Mailing Address - Phone:314-838-6600
Mailing Address - Fax:314-838-6611
Practice Address - Street 1:3533 DUNN RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6761
Practice Address - Country:US
Practice Address - Phone:314-838-6600
Practice Address - Fax:314-838-6611
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2017-02-22
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Provider Licenses
StateLicense IDTaxonomies
MO2010011996208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081399Medicaid
ILF68098Medicare UPIN
IL036081399Medicaid