1508977513 NPI number — KANKAKEE FAMILY MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508977513 NPI number — KANKAKEE FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KANKAKEE FAMILY MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1508977513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 NORTH WALL ST
Provider Second Line Business Mailing Address:
STE 504
Provider Business Mailing Address City Name:
KANKAKEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60901-2965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-932-4021
Provider Business Mailing Address Fax Number:
815-932-7270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 NORTH WALL ST
Provider Second Line Business Practice Location Address:
STE 504
Provider Business Practice Location Address City Name:
KANKAKEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60901-2965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-932-4021
Provider Business Practice Location Address Fax Number:
815-932-7270
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HANDY
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
815-932-4021

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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)