Provider Demographics
NPI:1780670430
Name:KENCOS, ANTIGONI (MD)
Entity Type:Individual
Prefix:
First Name:ANTIGONI
Middle Name:
Last Name:KENCOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E 86TH AVE
Mailing Address - Street 2:PO BOX 10645
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6382
Mailing Address - Country:US
Mailing Address - Phone:219-769-1670
Mailing Address - Fax:219-738-6714
Practice Address - Street 1:1201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8481
Practice Address - Country:US
Practice Address - Phone:219-757-6320
Practice Address - Fax:219-738-6714
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010315862085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND93906Medicare UPIN
IN405600 BMedicare ID - Type Unspecified
IN234800MMedicare PIN