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General NPI Number Information
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NPI Number | 1366579054
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Entity Type | Organization
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Legal Business Name | KENILWORTH MEDICAL ASSOCIATES, S.C.
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 11/20/2014
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Provider Practice Location Address
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Address Line | 534 GREEN BAY RD
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City | KENILWORTH
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State | IL
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Zip | 60043-1801
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Country | US
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Telephone | 847-256-5505
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Fax | 847-256-5567
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Provider Business Mailing Address
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Address Line | 534 GREEN BAY RD
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City | KENILWORTH
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State | IL
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Zip | 60043-1801
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Country | US
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Telephone | 847-256-5505
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Fax | 847-256-5567
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PAUL DETJEN
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Credential | MD
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Telephone | 847-256-5505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 036072795
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License Number State | IL
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