Provider Demographics
NPI:1235231366
Name:PRADEEP A KENI M D S C
Entity Type:Organization
Organization Name:PRADEEP A KENI M D S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PRADEEP
Authorized Official - Middle Name:A
Authorized Official - Last Name:KENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-371-3090
Mailing Address - Street 1:6420 W 127TH ST STE 106
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-2297
Mailing Address - Country:US
Mailing Address - Phone:708-371-3090
Mailing Address - Fax:708-371-1529
Practice Address - Street 1:6420 W 127TH ST STE 106
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-2297
Practice Address - Country:US
Practice Address - Phone:708-371-3090
Practice Address - Fax:708-371-1529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360-46184174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036046184Medicaid
IL21604442OtherBLUE SHIELD
IL21604442OtherBLUE SHIELD
ILD89236Medicare UPIN