MEDICARE: DR. KENDALL D BOONE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0127X	Trauma Surgery Physician	036101179	IL
2	2086S0129X	Vascular Surgery Physician	66852	WI
3	2086S0129X	Vascular Surgery Physician	036101179	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2045754001	OTHER	IL	OWCP
2	194273	OTHER	IL	PERSONAL CARE

General Provider Information

NPI Number	:	1861498909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENDALL D BOONE M.D.

Provider Business Mailing Address
First Line	:	7974 UW HEALTH CT
Second Line	:
City	:	MIDDLETON
State	:	WI
Zip	:	53562-5531
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 CHARLES ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61104-2200
Country	:	US
Telephone Number	:	779-696-8799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	03/21/2024

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