Provider Demographics
NPI:1609210657
Name:KEITH, MEGAN (NMT, MT-BC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:NMT, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6049 CRAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2941
Mailing Address - Country:US
Mailing Address - Phone:847-966-0251
Mailing Address - Fax:
Practice Address - Street 1:6049 CRAIN ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2941
Practice Address - Country:US
Practice Address - Phone:847-966-0251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILK300-5539-0779171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor