Provider Demographics
NPI:1275714834
Name:STALSBERG, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:STALSBERG
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 1:12400 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HART RD
Practice Address - Street 2:SUITE 115
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2623
Practice Address - Country:US
Practice Address - Phone:847-277-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7454077OtherAETNA
IL01622333OtherBLUE CROSS BLUE SHIELD