Provider Demographics
NPI:1831267921
Name:KEEN, MARY (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26W171 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-6078
Mailing Address - Country:US
Mailing Address - Phone:630-909-7337
Mailing Address - Fax:630-909-7039
Practice Address - Street 1:26W171 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-6078
Practice Address - Country:US
Practice Address - Phone:630-909-7337
Practice Address - Fax:630-909-7039
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.067113208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067113Medicaid
IL036067113Medicaid
ILE44511Medicare UPIN
ILL67348Medicare ID - Type Unspecified
ILL67348Medicare ID - Type Unspecified