Provider Demographics
NPI:1699883868
Name:KROCK, KENNETH R (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:KROCK
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 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2608
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5101
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-6880
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079829208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL079829OtherOSF HEALTHPLANS
ILCG5172OtherRR MEDICARE GROUP#
IL02922981OtherBCBS
IL200397OtherBLACK LUNG
IL013495OtherHEALTH ALLIANCE
IL036079829Medicaid
IL194215197OtherNPI CLINIC NUMBER
IL0062839OtherUMWA
IL110200867OtherRR MEDICARE PIN
IL180741OtherHEALTH LINK
ILIL0104OtherJOHN DEERE
ILIL0104OtherJOHN DEERE
IL200397OtherBLACK LUNG
ILL71182Medicare PIN