1497975502 NPI number — KENNETH HA D.O.

Table of content: KENNETH HA D.O. (NPI 1497975502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497975502 NPI number — KENNETH HA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HA
Provider First Name:
KENNETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1497975502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
444 N PARK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ELLYN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60137-4622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-469-0045
Provider Business Mailing Address Fax Number:
630-469-0645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 N PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ELLYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60137-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-469-0045
Provider Business Practice Location Address Fax Number:
630-469-0645
Provider Enumeration Date:
04/30/2007

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: 207Q00000X , with the licence number:  036116719 , 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: 3631498336019001 . This is a "CDPG HFS PAYEE ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 363149833 . This is a "TAX ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036116719 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0222075 . This is a "BLUE CROSS GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1033149844 . This is a "ORGANIZATION NPI" identifier . This identifiers is of the category "OTHER".




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