Healthcare Provider Details

I. General information

NPI: 1417937632
Provider Name (Legal Business Name): ALPHEUS T APPENHEIMER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KSB MEDICAL GROUP 102 S HENNEPIN AVE
DIXON IL
61021
US

IV. Provider business mailing address

403 E 1ST ST
DIXON IL
61021-3116
US

V. Phone/Fax

Practice location:
  • Phone: 815-288-7711
  • Fax: 815-285-8903
Mailing address:
  • Phone: 815-285-8504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-058868
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number036-058868
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036-058868
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: