Healthcare Provider Details

I. General information

NPI: 1184687717
Provider Name (Legal Business Name): MICHAEL A AHEARN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 ELLIOTT ST SUITE S1
KEWANEE IL
61443-2796
US

IV. Provider business mailing address

519 ELLIOTT ST SUITE S1
KEWANEE IL
61443-2796
US

V. Phone/Fax

Practice location:
  • Phone: 309-853-2442
  • Fax:
Mailing address:
  • Phone: 309-853-2442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036074050
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: