Provider Demographics
NPI:1609405026
Name:ABOU-KASSEM, KINAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:KINAN
Middle Name:J
Last Name:ABOU-KASSEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E CARPENTER STREET BOX 43
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-814-5178
Mailing Address - Fax:217-757-6458
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-1000
Practice Address - Country:US
Practice Address - Phone:217-814-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
MO20210224272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program