Provider Demographics
NPI:1568475259
Name:BAUMRUCK, KENNETH ERVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ERVIN
Last Name:BAUMRUCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 S. MAIN ST.
Mailing Address - Street 2:P.O. BOX 382
Mailing Address - City:ELBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60119
Mailing Address - Country:US
Mailing Address - Phone:630-365-5432
Mailing Address - Fax:630-365-6160
Practice Address - Street 1:319 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119
Practice Address - Country:US
Practice Address - Phone:630-365-5432
Practice Address - Fax:630-365-6160
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL673431Medicare ID - Type Unspecified
ILT37712Medicare UPIN