Provider Demographics
NPI:1639166226
Name:SCHAIDLE, KENNETH A (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:SCHAIDLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:4620 N UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5889
Practice Address - Country:US
Practice Address - Phone:309-692-8222
Practice Address - Fax:309-692-8226
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008408Medicaid
IL410033418OtherMEDICARE RAILROAD
IL7215175OtherBCBS
IL046008408Medicaid
ILK04661Medicare PIN
IL0295700002Medicare NSC