Provider Demographics
NPI:1538129069
Name:KEITH, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:KEITH
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 1:6785 WEAVER RD
Mailing Address - Street 2:STE D
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8055
Mailing Address - Country:US
Mailing Address - Phone:815-633-2225
Mailing Address - Fax:
Practice Address - Street 1:2400 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3655
Practice Address - Country:US
Practice Address - Phone:815-971-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064581207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL380570Medicare PIN