1699883868 NPI number — KENNETH R. KROCK MD

Table of content: (NPI 1356523526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699883868 NPI number — KENNETH R. KROCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KROCK
Provider First Name:
KENNETH
Provider Middle Name:
R.
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:
1699883868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61520-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-647-0201
Provider Business Mailing Address Fax Number:
309-649-5101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61520-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-647-0201
Provider Business Practice Location Address Fax Number:
309-649-6880
Provider Enumeration Date:
08/28/2006

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: 208000000X , with the licence number:  036079829 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 036079829 , 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: 079829 . This is a "OSF HEALTHPLANS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CG5172 . This is a "RR MEDICARE GROUP#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 02922981 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200397 . This is a "BLACK LUNG" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 013495 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036079829 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 194215197 . This is a "NPI CLINIC NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0062839 . This is a "UMWA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 110200867 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 180741 . This is a "HEALTH LINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL0104 . This is a "JOHN DEERE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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