Healthcare Provider Details

I. General information

NPI: 1538146758
Provider Name (Legal Business Name): PAUL M KENTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 ROGER WILLIAMS AVE STE 25
HIGHLAND PARK IL
60035-4820
US

IV. Provider business mailing address

580 ROGER WILLIAMS AVE STE 25
HIGHLAND PARK IL
60035-4820
US

V. Phone/Fax

Practice location:
  • Phone: 847-634-1960
  • Fax: 847-864-0661
Mailing address:
  • Phone: 847-634-1960
  • Fax: 847-864-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036044332
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: