Provider Demographics
NPI:1124223763
Name:KENNETH J LIESEN MD SC
Entity type:Organization
Organization Name:KENNETH J LIESEN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-584-8900
Mailing Address - Street 1:606 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2969
Mailing Address - Country:US
Mailing Address - Phone:630-584-8900
Mailing Address - Fax:630-584-2806
Practice Address - Street 1:606 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2969
Practice Address - Country:US
Practice Address - Phone:630-584-8900
Practice Address - Fax:630-584-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077277Medicaid
IL966700OtherINDIVIDUAL MEDICARE PTAN
IL036077277OtherBCBS
IL943790OtherGROUP PTAN
IL036077277Medicaid