Provider Demographics
NPI:1508967621
Name:KEENE, MATTHEW S (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:S
Last Name:KEENE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4777 EAST STATE STREET
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-980-8980
Mailing Address - Fax:815-397-2266
Practice Address - Street 1:4777 EAST STATE STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-980-8980
Practice Address - Fax:815-397-2266
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005216213E00000X, 213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL010132351OtherILLINOIS BLUE CROSS
IL016005216Medicaid
IL6151850001Medicare NSC
IL010132351OtherILLINOIS BLUE CROSS
IL217165Medicare UPIN