Provider Demographics
NPI:1932335668
Name:KEEDY, MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KEEDY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S MAJOR ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1246
Mailing Address - Country:US
Mailing Address - Phone:309-304-2004
Mailing Address - Fax:309-467-2880
Practice Address - Street 1:101 S MAJOR ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1246
Practice Address - Country:US
Practice Address - Phone:309-304-2004
Practice Address - Fax:309-467-2880
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007640367500000X
IL041-343146390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGOtherMEDICARE