Healthcare Provider Details

I. General information

NPI: 1114668654
Provider Name (Legal Business Name): JOHN MICHAEL KASCHKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PIERCE BLVD
O FALLON IL
62269-2579
US

IV. Provider business mailing address

670 PIERCE BLVD
O FALLON IL
62269-2579
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-2070
  • Fax: 618-206-2071
Mailing address:
  • Phone: 618-206-2070
  • Fax: 618-206-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036179529
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: