Provider Demographics
NPI:1831297761
Name:KAKAC, KYLE D (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:D
Last Name:KAKAC
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 1:303 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-1203
Mailing Address - Country:US
Mailing Address - Phone:618-847-8260
Mailing Address - Fax:618-847-8387
Practice Address - Street 1:303 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1203
Practice Address - Country:US
Practice Address - Phone:618-842-2611
Practice Address - Fax:618-847-8386
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057262207P00000X
IL036116009207Q00000X, 208M00000X
IL036-116009207P00000X
TN41240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1534607Medicaid
IN200522020Medicaid
IL3932056OtherBLUE SHIELD
IL036116009-4Medicaid
IN200522020Medicaid
820900Medicare PIN
IL3932056OtherBLUE SHIELD
IL036116009-4Medicaid
TN1534607Medicaid