Healthcare Provider Details

I. General information

NPI: 1134197833
Provider Name (Legal Business Name): KENNTH ALAN HODEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6915 N KNOXVILLE AVE SUITE 1
PEORIA IL
61614-2851
US

IV. Provider business mailing address

6915 N KNOXVILLE AVE SUITE 1
PEORIA IL
61614
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-8910
  • Fax: 309-683-8911
Mailing address:
  • Phone: 309-683-8910
  • Fax: 309-683-8911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: