Healthcare Provider Details

I. General information

NPI: 1174529556
Provider Name (Legal Business Name): KENNETH MAX EAKIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 JUNCTION DR W
GLEN CARBON IL
62034-2916
US

IV. Provider business mailing address

3 JUNCTION DR W
GLEN CARBON IL
62034-2916
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-5088
  • Fax: 618-288-9153
Mailing address:
  • Phone: 618-288-5088
  • Fax: 618-288-9153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036066196
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: