Provider Demographics
NPI:1326017484
Name:BECK, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:BECK
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 1:3183 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0031
Mailing Address - Country:US
Mailing Address - Phone:708-492-0502
Mailing Address - Fax:708-492-0565
Practice Address - Street 1:2225 ENTERPRISE DR
Practice Address - Street 2:SUITE 2511
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5814
Practice Address - Country:US
Practice Address - Phone:708-486-0076
Practice Address - Fax:708-486-0080
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087177207ZP0105X
IL036087177207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635877OtherBLUE SHIELD
IL0360871774Medicaid
ILP00397046OtherRAILROAD MEDICARE
ILP00397046OtherRAILROAD MEDICARE
G38158Medicare UPIN
IL01635877OtherBLUE SHIELD