Healthcare Provider Details

I. General information

NPI: 1720273378
Provider Name (Legal Business Name): SANJAY PRADEEP KENI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 W 127TH ST
PALOS HEIGHTS IL
60463-2269
US

IV. Provider business mailing address

6420 W 127TH ST
PALOS HEIGHTS IL
60463-2269
US

V. Phone/Fax

Practice location:
  • Phone: 708-371-3090
  • Fax: 708-371-1529
Mailing address:
  • Phone: 708-371-3090
  • Fax: 708-371-1529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number036121277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: