1598705196 NPI number — KENNETH Q CRUZ MD

Table of content: KENNETH Q CRUZ MD (NPI 1598705196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598705196 NPI number — KENNETH Q CRUZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRUZ
Provider First Name:
KENNETH
Provider Middle Name:
Q
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1598705196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 WEST RTE 22
Provider Second Line Business Mailing Address:
SUITE 50
Provider Business Mailing Address City Name:
LAKE ZURICH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-344-0543
Provider Business Mailing Address Fax Number:
866-344-3934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 W CENTRAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60005-2349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-655-2656
Provider Business Practice Location Address Fax Number:
412-822-7411
Provider Enumeration Date:
06/08/2006

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: 207R00000X , with the licence number:  036.100876 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: A90441 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: A90441 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A904410 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00A904410 . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".