Healthcare Provider Details

I. General information

NPI: 1730114612
Provider Name (Legal Business Name): JOSEPH KENYON ASBURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 N NORTH BRANCH ST SUITE 206
CHICAGO IL
60642-2473
US

IV. Provider business mailing address

1229 N NORTH BRANCH ST SUITE 206
CHICAGO IL
60642-2473
US

V. Phone/Fax

Practice location:
  • Phone: 312-939-5090
  • Fax: 312-640-4496
Mailing address:
  • Phone: 312-030-5090
  • Fax: 312-640-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number114324
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036114324
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: