1790779361 NPI number — KENNETH S POLIN M.D.

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 1790779361 NPI number — KENNETH S POLIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLIN
Provider First Name:
KENNETH
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1790779361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1460 N HALSTED ST
Provider Second Line Business Mailing Address:
SUITE 402
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-279-8900
Provider Business Mailing Address Fax Number:
312-981-6312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 COMPASS RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-998-8806
Provider Business Practice Location Address Fax Number:
847-998-8807
Provider Enumeration Date:
09/09/2005

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:  036065528 , 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)





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