Provider Demographics
NPI:1003847393
Name:BOYER, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:BOYER
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 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 710
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-3034
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 710
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-055224208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP10558Medicare ID - Type Unspecified
ILD13349Medicare UPIN