Provider Demographics
NPI:1225017957
Name:PANOZZO, KERRY P (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:P
Last Name:PANOZZO
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 1:4110 BLACKHAWK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7039
Mailing Address - Country:US
Mailing Address - Phone:309-428-7055
Mailing Address - Fax:309-265-0118
Practice Address - Street 1:4110 BLACKHAWK RD STE 2
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7039
Practice Address - Country:US
Practice Address - Phone:309-428-7055
Practice Address - Fax:309-265-0118
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090677207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090677Medicaid
ILG54845Medicare UPIN
IL467770Medicare ID - Type Unspecified