Provider Demographics
NPI:1588659130
Name:ANN E KINNEALEY MD PC
Entity Type:Organization
Organization Name:ANN E KINNEALEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONCOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:KINNEALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-869-2076
Mailing Address - Street 1:9266 PAYSPHERE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0052
Mailing Address - Country:US
Mailing Address - Phone:847-869-2076
Mailing Address - Fax:847-475-3414
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:STE 557
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-869-2076
Practice Address - Fax:847-475-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036050081207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050081Medicaid
IL036050081Medicaid
IL5042670001Medicare NSC