1093752370 NPI number — JOSEPH J KEELEY MD

Table of content: JOSEPH J KEELEY MD (NPI 1093752370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093752370 NPI number — JOSEPH J KEELEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEELEY
Provider First Name:
JOSEPH
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093752370
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 W UNIVERSITY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61820-3909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-366-8107
Provider Business Mailing Address Fax Number:
217-366-6106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 WINDSOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822-6217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-366-1257
Provider Business Practice Location Address Fax Number:
217-366-6106
Provider Enumeration Date:
06/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  036127075 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 253779600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42928 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 370010629 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".