Healthcare Provider Details

I. General information

NPI: 1609405026
Provider Name (Legal Business Name): KINAN J ABOU-KASSEM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST
SPRINGFIELD IL
62769-1000
US

IV. Provider business mailing address

800 E CARPENTER STREET BOX 43
SPRINGFIELD IL
62769-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-814-5178
  • Fax:
Mailing address:
  • Phone: 217-814-5178
  • Fax: 217-757-6458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2021022427
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME182733
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: