Healthcare Provider Details

I. General information

NPI: 1972769222
Provider Name (Legal Business Name): KIRK KITTIKAMRON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

2000 SPRING RD SUITE 200
OAK BROOK IL
60523-1804
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-3800
  • Fax: 773-907-1005
Mailing address:
  • Phone: 630-581-6507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-115441
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: