Healthcare Provider Details

I. General information

NPI: 1255351276
Provider Name (Legal Business Name): KENNETH ADAMS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 SWEETBRIAR DR
CHILLICOTHEE IL
61523
US

IV. Provider business mailing address

5100 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-274-2102
  • Fax:
Mailing address:
  • Phone: 309-672-4240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number036071354
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: