Healthcare Provider Details

I. General information

NPI: 1083674295
Provider Name (Legal Business Name): JAMES MARTIN KEDROW PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

1806 MIDDAY DR
ZION IL
60099-9252
US

V. Phone/Fax

Practice location:
  • Phone: 847-688-6755
  • Fax:
Mailing address:
  • Phone: 847-688-6755
  • Fax: 847-688-2722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number921-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: