MEDICARE: ERIC A KIVISTO DO

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	208600000X	Surgery Physician	5101011210	MI
2	208600000X	Surgery Physician	036091073	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	371342699	OTHER	IL	FEIN NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	02706617	OTHER	IL	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1447257316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC A KIVISTO DO

Provider Business Mailing Address
First Line	:	1401 E 12TH ST
Second Line	:
City	:	MENDOTA
State	:	IL
Zip	:	61342-9216
Country	:	US
Telephone Number	:	815-539-1789
Fax Number	:	815-539-1430

Provider Business Practice Location Address
First Line	:	1405 E 12TH ST
Second Line	:	SUITE 500
City	:	MENDOTA
State	:	IL
Zip	:	61342-9010
Country	:	US
Telephone Number	:	815-539-1789
Fax Number	:	815-539-1430

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

Provider Enumeration Date	:	07/06/2005
Last Update Date	:	12/07/2022

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Directions to “ ERIC A KIVISTO DO” Practice Location

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