Provider Demographics
NPI:1790783249
Name:WILLIAMS, KENNETH D (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:WILLIAMS
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 2153
Mailing Address - Street 2:
Mailing Address - City:BEDFORD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60499-2153
Mailing Address - Country:US
Mailing Address - Phone:800-354-1088
Mailing Address - Fax:314-631-4491
Practice Address - Street 1:2701 W 68TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1813
Practice Address - Country:US
Practice Address - Phone:773-884-9000
Practice Address - Fax:314-631-4491
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361012202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK05336Medicare ID - Type UnspecifiedMEDICARE #
ILK52585Medicare PIN
ILE24018Medicare UPIN