Provider Demographics
NPI:1457306649
Name:BIELINSKI, KENNETH B (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:BIELINSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 E WATERSIDE DR UNIT 3107
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-4733
Mailing Address - Country:US
Mailing Address - Phone:815-919-9233
Mailing Address - Fax:
Practice Address - Street 1:900 E DURANT AVE APT 113
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-2613
Practice Address - Country:US
Practice Address - Phone:815-919-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-070977207ND0101X, 207ND0900X, 207NS0135X, 207N00000X
COBIEL0051223207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK28344Medicare ID - Type Unspecified
ILC43724Medicare UPIN
ILK29544Medicare ID - Type Unspecified