Provider Demographics
NPI:1164493854
Name:WARREN, KEITH REYNOLDS (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:REYNOLDS
Last Name:WARREN
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 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:630-690-4993
Mailing Address - Fax:630-690-2293
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:630-690-4993
Practice Address - Fax:630-690-2293
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT42-0010962207R00000X
IL036125979207RS0012X, 2084P0800X
NH130592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400188615OtherMEDICARE PTAN (INDIVIDUAL)
IL206147OtherMEDICARE PTAN (GROUP)
IL036125979Medicaid
IL745440007Medicare PIN
IL209308012Medicare PIN
ILF400188615OtherMEDICARE PTAN (INDIVIDUAL)