Provider Demographics
NPI:1740232560
Name:ISRAELSEN, KLEVEN H (DO)
Entity Type:Individual
Prefix:
First Name:KLEVEN
Middle Name:H
Last Name:ISRAELSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GOLDENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-6972
Mailing Address - Country:US
Mailing Address - Phone:630-585-9320
Mailing Address - Fax:
Practice Address - Street 1:925 WEST ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2757
Practice Address - Country:US
Practice Address - Phone:815-223-3300
Practice Address - Fax:815-223-3394
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083343207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083343-8Medicaid
IL214881057Medicare PIN
ILE67888Medicare UPIN
ILK13566Medicare PIN