Provider Demographics
NPI:1497723084
Name:IFFT, KEITH HARVEY (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:HARVEY
Last Name:IFFT
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:PO BOX 10345
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61612-0345
Mailing Address - Country:US
Mailing Address - Phone:309-360-2600
Mailing Address - Fax:
Practice Address - Street 1:210 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2444
Practice Address - Country:US
Practice Address - Phone:309-360-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072713207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072713Medicaid
IL036072713Medicaid
ILL89592Medicare ID - Type Unspecified