Provider Demographics
NPI:1619954583
Name:MICETICH, KENNETH CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:CRAIG
Last Name:MICETICH
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 1:2160 S 1ST AVE
Mailing Address - Street 2:(15750 MARION DR., HOMER GLEN, IL. 60491)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-645-3400
Mailing Address - Fax:708-645-3411
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(15750 MARION DR., HOMER GLEN, IL. 60491)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-645-3400
Practice Address - Fax:708-645-3411
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36056032207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36056032Medicaid
IL36056032Medicaid
C45421Medicare UPIN