Provider Demographics
NPI:1487651550
Name:PELEHAC, KENNETH M (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:PELEHAC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5404 FOXWOODS DR
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5073
Mailing Address - Country:US
Mailing Address - Phone:708-382-1615
Mailing Address - Fax:888-702-1052
Practice Address - Street 1:5404 FOXWOODS DR
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-382-1615
Practice Address - Fax:888-702-1052
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085109208600000X, 2086S0102X
WI49770208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF51451Medicare UPIN
IL209367/K07920Medicare PIN