Healthcare Provider Details

I. General information

NPI: 1730448481
Provider Name (Legal Business Name): ILONA A KICHKO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

555 W COURT ST STE 412
KANKAKEE IL
60901-3675
US

V. Phone/Fax

Practice location:
  • Phone: 773-975-1600
  • Fax:
Mailing address:
  • Phone: 815-928-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036143477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: