Provider Demographics
NPI:1417937632
Name:APPENHEIMER, ALPHEUS T (MD)
Entity Type:Individual
Prefix:DR
First Name:ALPHEUS
Middle Name:T
Last Name:APPENHEIMER
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 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-285-8504
Mailing Address - Fax:
Practice Address - Street 1:KSB MEDICAL GROUP
Practice Address - Street 2:102 S HENNEPIN AVE
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-288-7711
Practice Address - Fax:815-285-8903
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-058868207Q00000X, 207QH0002X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058868Medicaid
C45310Medicare UPIN