Provider Demographics
NPI:1568028744
Name:KERRY PANOZZO MD PC
Entity Type:Organization
Organization Name:KERRY PANOZZO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:PANOZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-428-7055
Mailing Address - Street 1:4110 BLACKHAWK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7039
Mailing Address - Country:US
Mailing Address - Phone:309-428-7055
Mailing Address - Fax:
Practice Address - Street 1:3170 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3864
Practice Address - Country:US
Practice Address - Phone:309-428-7055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KERRY PANOZZO MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain