Provider Demographics
NPI:1184687717
Name:AHEARN, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:AHEARN
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 1:519 ELLIOTT ST
Mailing Address - Street 2:SUITE S1
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-2796
Mailing Address - Country:US
Mailing Address - Phone:309-853-2442
Mailing Address - Fax:
Practice Address - Street 1:519 ELLIOTT ST
Practice Address - Street 2:SUITE S1
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-2796
Practice Address - Country:US
Practice Address - Phone:309-853-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36074050OtherBCBS
ILP00196862OtherRAILROAD MEDICARE
IL036074050Medicaid
IL036074050Medicaid
ILD16625Medicare UPIN