Healthcare Provider Details

I. General information

NPI: 1114455680
Provider Name (Legal Business Name): MITCHELL KENTOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 07/21/2022
Certification Date: 01/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5375
  • Fax:
Mailing address:
  • Phone: 708-684-5375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125070692
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: