Provider Demographics
NPI:1326045568
Name:BLUESTONE, KENNETH I (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:I
Last Name:BLUESTONE
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:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-0229
Mailing Address - Country:US
Mailing Address - Phone:618-257-5050
Mailing Address - Fax:618-233-1061
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:618-257-4376
Practice Address - Fax:618-257-5196
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138832207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00056031OtherRAILROAD MEDICARE
MOA13684Medicare UPIN
MO042011545Medicare PIN