Healthcare Provider Details

I. General information

NPI: 1699883868
Provider Name (Legal Business Name): KENNETH R. KROCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST
CANTON IL
61520-2608
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-649-6880
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-649-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036079829
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036079829
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: