Provider Demographics
NPI:1790868008
Name:KIKEN, STUART (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:KIKEN
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 1:2720 W 15TH ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1610
Mailing Address - Country:US
Mailing Address - Phone:773-257-6730
Mailing Address - Fax:773-257-4775
Practice Address - Street 1:2720 W 15TH ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1610
Practice Address - Country:US
Practice Address - Phone:773-257-6730
Practice Address - Fax:773-257-4775
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-059941207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F19719Medicare UPIN
367830Medicare PIN