Healthcare Provider Details

I. General information

NPI: 1013630920
Provider Name (Legal Business Name): KEVIN PENA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1550 N LAKE SHORE DR APT 4D
CHICAGO IL
60610-1638
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 347-483-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number125.081092
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: