Healthcare Provider Details

I. General information

NPI: 1619954583
Provider Name (Legal Business Name): KENNETH CRAIG MICETICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE (15750 MARION DR., HOMER GLEN, IL. 60491)
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE (15750 MARION DR., HOMER GLEN, IL. 60491)
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-645-3400
  • Fax: 708-645-3411
Mailing address:
  • Phone: 708-645-3400
  • Fax: 708-645-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number36056032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: