Provider Demographics
NPI:1750323424
Name:CAMACHO, KENNETH B (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:CAMACHO
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:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-0365
Mailing Address - Country:US
Mailing Address - Phone:309-672-4980
Mailing Address - Fax:309-671-2944
Practice Address - Street 1:1301 PLEASANT VALLEY RD STE 401
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7800
Practice Address - Fax:270-417-7809
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57390207RG0100X
IL036101777207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101777Medicaid
IL371221637OtherFEDERAL TAX ID
ILIL0114OtherJOHN DEERE
IL07215152OtherBLUE CROSS
IL100014760OtherRAILROAD MEDICARE
IL426249OtherHEALTHLINK
IL067597OtherHEALTH ALLIANCE
IL776530OtherMEDICARE GROUP NUMBER
IL7036279OtherAETNA HEALTH PLANS
KY7100877910Medicaid
ILF50108Medicare UPIN