Provider Demographics
NPI:1194826115
Name:FRASER, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:FRASER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10335 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 HAMILTON BLVD
Practice Address - Street 2:1824
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1144
Practice Address - Country:US
Practice Address - Phone:309-494-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0885682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE28572Medicare UPIN
L79527Medicare PIN