Provider Demographics
NPI:1851461289
Name:KUZNETSKY, KENNETH ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALLEN
Last Name:KUZNETSKY
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 1:2253 N GENEVA TER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3746
Mailing Address - Country:US
Mailing Address - Phone:773-348-4640
Mailing Address - Fax:773-794-4698
Practice Address - Street 1:5645 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4403
Practice Address - Country:US
Practice Address - Phone:773-348-4640
Practice Address - Fax:773-794-4698
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
31601236OtherBLUE CROSS BLUE SHIELD
31601236OtherBLUE CROSS BLUE SHIELD
C46127Medicare UPIN