Provider Demographics
NPI:1083633473
Name:KONCHANIN, RONALD P (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:P
Last Name:KONCHANIN
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:UROLOGY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3160
Practice Address - Fax:217-383-4868
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100175208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E52795Medicare UPIN
IL0533210001Medicare NSC
ILIL3270080Medicare PIN
ILE52795Medicare UPIN
IL6447860011Medicare NSC