Provider Demographics
NPI:1801007190
Name:MARTIN, KEITH R (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:MARTIN
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 1:2407 W GALENA AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-2903
Mailing Address - Country:US
Mailing Address - Phone:815-275-3665
Mailing Address - Fax:
Practice Address - Street 1:1010 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6600
Practice Address - Country:US
Practice Address - Phone:815-599-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084645207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084645Medicaid
IL08932003OtherBLUE CROSS BLUE SHIELD OF
IL08932003OtherBLUE CROSS BLUE SHIELD OF