Provider Demographics
NPI:1710980750
Name:KEOHANE, MARK K (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:KEOHANE
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 1:9323 PHOENIX VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-4281
Mailing Address - Country:US
Mailing Address - Phone:636-561-5030
Mailing Address - Fax:636-561-5033
Practice Address - Street 1:9323 PHOENIX VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-4281
Practice Address - Country:US
Practice Address - Phone:636-561-5030
Practice Address - Fax:636-561-5033
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34653207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4061116OtherAETNA
43177OtherCMR
18883OtherBLUE CROSS BLUE SHIELD
122683OtherHEALTHLINK
351240001OtherCIGNA DMERC
900094OtherUHC
4434V6097OtherHEALTHCARE USA
9043OtherEXCLUSIVE CHOICE
2253V3458OtherGHP/ADVANTRA
SP10133OtherCIGNA
A10911Medicare UPIN
2253V3458OtherGHP/ADVANTRA
4061116OtherAETNA