Provider Demographics
NPI:1588611834
Name:PILZ, KYLE R (PA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:PILZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 W HARRISON ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:877-632-6637
Mailing Address - Fax:708-409-5179
Practice Address - Street 1:1611 W HARRISON ST STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:877-632-6637
Practice Address - Fax:708-409-5179
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002192363AS0400X
IN10003828A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209118OtherMEDICARE PTAN LOCALITY 15
IL209119OtherMEDICARE PTAN LOCALITY 16
ILK14131Medicare PIN
ILK14130Medicare PIN
ILQ33760Medicare UPIN