MEDICARE: K C A S ENT INC.

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	363LP0200X	Pediatric Nurse Practitioner	209000890	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659373132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K C A S ENT INC.

Provider Business Mailing Address
First Line	:	706 N TAYLOR ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2457
Country	:	US
Telephone Number	:	815-568-0243
Fax Number	:	815-568-5350

Provider Business Practice Location Address
First Line	:	706 N TAYLOR ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2457
Country	:	US
Telephone Number	:	815-568-0243
Fax Number	:	815-568-5350

Authorized Official
Title or Position	:	ADVANCED PRACTICE NURSE PRACTITIONE
Name	:	MRS. KATHLEEN L LUDWIKOWSKI
Credential	:	APN
Telephone Number	:	815-568-0243

Provider Enumeration Date	:	08/13/2005
Last Update Date	:	11/24/2010

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Directions to “K C A S ENT INC. ” Practice Location

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