Provider Demographics
NPI:1497975502
Name:HA, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HA
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 1:444 N PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4622
Mailing Address - Country:US
Mailing Address - Phone:630-469-0045
Mailing Address - Fax:630-469-0645
Practice Address - Street 1:444 N PARK BLVD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4622
Practice Address - Country:US
Practice Address - Phone:630-469-0045
Practice Address - Fax:630-469-0645
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3631498336019001OtherCDPG HFS PAYEE ID
IL363149833OtherTAX ID
IL036116719Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER
1033149844OtherORGANIZATION NPI
IL036116719Medicaid
IL487450Medicare PIN
1033149844OtherORGANIZATION NPI
IL920780Medicare PIN