MEDICARE: DR. CHARLES KITCHEN 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	2084P0800X	Psychiatry Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21605259	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1841299732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES KITCHEN M.D.

Provider Business Mailing Address
First Line	:	1187 WILMETTE AVE
Second Line	:	#340
City	:	WILMETTE
State	:	IL
Zip	:	60091-2719
Country	:	US
Telephone Number	:	312-236-0990
Fax Number	:	847-251-5147

Provider Business Practice Location Address
First Line	:	1187 WILMETTE AVE
Second Line	:	#340
City	:	WILMETTE
State	:	IL
Zip	:	60091-2719
Country	:	US
Telephone Number	:	312-236-0990
Fax Number	:	847-251-5147

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	12/31/2007

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Directions to “ DR. CHARLES KITCHEN M.D.” Practice Location

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