Provider Demographics
NPI:1366579054
Name:KENILWORTH MEDICAL ASSOCIATES, S.C.
Entity type:Organization
Organization Name:KENILWORTH MEDICAL ASSOCIATES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DETJEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-256-5505
Mailing Address - Street 1:534 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1801
Mailing Address - Country:US
Mailing Address - Phone:847-256-5505
Mailing Address - Fax:847-256-5567
Practice Address - Street 1:534 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1801
Practice Address - Country:US
Practice Address - Phone:847-256-5505
Practice Address - Fax:847-256-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072795207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072795Medicaid
IL036072795Medicaid
IL553740Medicare ID - Type Unspecified