Healthcare Provider Details

I. General information

NPI: 1699039404
Provider Name (Legal Business Name): LOUIS KIENZLER GRAHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST SUITE 3100
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

751 N RUTLEDGE ST PO BOX 19643
SPRINGFIELD IL
62702-4968
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-545-7393
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-7393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036-142743
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036-142743
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: