Provider Demographics
NPI:1225183890
Name:SCHMIDT, KENNETH WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:SCHMIDT
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 1:125 E PLUMMER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-8136
Mailing Address - Country:US
Mailing Address - Phone:217-483-3333
Mailing Address - Fax:217-483-4393
Practice Address - Street 1:125 E PLUMMER BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629
Practice Address - Country:US
Practice Address - Phone:217-483-3333
Practice Address - Fax:217-483-4393
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076398Medicaid
IL036076398Medicaid
906150Medicare ID - Type Unspecified