Provider Demographics
NPI:1891814653
Name:ORCHARD, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:ORCHARD
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 1:1035 VALLEY STREAM DR
Mailing Address - Street 2:
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9137
Mailing Address - Country:US
Mailing Address - Phone:615-260-5205
Mailing Address - Fax:
Practice Address - Street 1:1035 VALLEY STREAM DR
Practice Address - Street 2:
Practice Address - City:PINGREE GROVE
Practice Address - State:IL
Practice Address - Zip Code:60140-9137
Practice Address - Country:US
Practice Address - Phone:615-260-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN287152083X0100X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I082013OtherMEDICARE MCRPTAN
TN103I082013OtherMEDICARE MCRPTAN
TN3370244Medicare PIN