Provider Demographics
NPI:1386832855
Name:KEFALAS, JOHN CHRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHRIS
Last Name:KEFALAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2905 N MAIN ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4276
Mailing Address - Country:US
Mailing Address - Phone:217-425-2600
Mailing Address - Fax:217-425-2900
Practice Address - Street 1:2905 N MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4276
Practice Address - Country:US
Practice Address - Phone:217-425-2600
Practice Address - Fax:217-425-2900
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36094691207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-094691Medicaid
IL201618Medicare PIN
IL5377260001Medicare NSC