Provider Demographics
NPI:1194895821
Name:KUCHEFSKI, ERIC (PA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:KUCHEFSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:SLEEP MEDICINE
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3190
Practice Address - Fax:217-383-7117
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP91809Medicare UPIN
ILIL3270384Medicare PIN
IL206121Medicare PIN
IL6447860014Medicare NSC
P91809Medicare UPIN
IL0533210001Medicare NSC