Provider Demographics
NPI:1790899979
Name:KIRCHNER, PAUL BERNARD (DPM)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:BERNARD
Last Name:KIRCHNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1871
Mailing Address - Country:US
Mailing Address - Phone:815-485-0760
Mailing Address - Fax:815-463-6138
Practice Address - Street 1:250 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1871
Practice Address - Country:US
Practice Address - Phone:815-485-0760
Practice Address - Fax:815-463-6138
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004527213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004527Medicaid
625430Medicare ID - Type Unspecified
U18379Medicare UPIN