Provider Demographics
NPI:1982785572
Name:KRISE, KEVIN MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MATTHEW
Last Name:KRISE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5970
Mailing Address - Country:US
Mailing Address - Phone:312-695-0990
Mailing Address - Fax:312-695-1106
Practice Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5970
Practice Address - Country:US
Practice Address - Phone:312-695-0990
Practice Address - Fax:312-695-1106
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04678363A00000X
IL085.006901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00677105OtherRR MEDICARE
TX8Y0727OtherBCBS
TX184834301Medicaid
TX8J2864Medicare PIN