MEDICARE: KENNETH MAX EAKIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036066196	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080021116	OTHER	IL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0107335	OTHER		UNITED HEALTHCARE
3	371205888	OTHER		TAX ID
4	118802	OTHER		HEALTHLINK
5	N4882	OTHER		GROUP HEALTH PLAN
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	4622029	OTHER	IL	ADMINISTAR

General Provider Information

NPI Number	:	1174529556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH MAX EAKIN M.D.

Provider Business Mailing Address
First Line	:	3 JUNCTION DR W
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2916
Country	:	US
Telephone Number	:	618-288-5088
Fax Number	:	618-288-9153

Provider Business Practice Location Address
First Line	:	3 JUNCTION DR W
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2916
Country	:	US
Telephone Number	:	618-288-5088
Fax Number	:	618-288-9153

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	04/30/2008

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Directions to “ KENNETH MAX EAKIN M.D.” Practice Location

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