Provider Demographics
NPI:1275566317
Name:KANDIS, ANN FOTIADIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:FOTIADIS
Last Name:KANDIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4435 6TH STREET CT
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-4275
Mailing Address - Country:US
Mailing Address - Phone:309-796-6179
Mailing Address - Fax:
Practice Address - Street 1:106 19TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3700
Practice Address - Country:US
Practice Address - Phone:309-779-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28332207Q00000X
IL036.126806207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA8065904Medicaid
IA1065904Medicaid
15346Medicare ID - Type Unspecified
IA1065904Medicaid