Healthcare Provider Details

I. General information

NPI: 1457327173
Provider Name (Legal Business Name): KENNETH S OBARSKI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HUEHL RD UNIT 13
NORTHBROOK IL
60062-2322
US

IV. Provider business mailing address

10580 OLCOTT AVE
ST JOHN IN
46373-8942
US

V. Phone/Fax

Practice location:
  • Phone: 847-504-5000
  • Fax: 847-504-5015
Mailing address:
  • Phone: 219-558-8540
  • Fax: 219-627-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016-003964
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number07000623A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: