Provider Demographics
NPI:1346249125
Name:MCILWAINE, JOHN KEITH (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KEITH
Last Name:MCILWAINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-0002
Practice Address - Country:US
Practice Address - Phone:570-271-6389
Practice Address - Fax:570-271-6021
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013009207R00000X, 207RC0200X
MA227083207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011340930001Medicaid
MA2114534Medicaid
H31861Medicare UPIN
MA2114534Medicaid