Provider Demographics
NPI:1902028293
Name:MACEK, KENNETH RIDGE (M D)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RIDGE
Last Name:MACEK
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28375 DAVIS PKWY
Mailing Address - Street 2:SUITE 901
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3030
Mailing Address - Country:US
Mailing Address - Phone:630-653-4240
Mailing Address - Fax:630-255-4034
Practice Address - Street 1:28375 DAVIS PKWY
Practice Address - Street 2:SUITE 901
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3030
Practice Address - Country:US
Practice Address - Phone:630-653-4240
Practice Address - Fax:630-255-4034
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-117591207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147213OtherMEDICARE PTAN (INDIVIDUAL)
ILP01258413OtherMEDICARE RAILROAD (INDIVIDUAL)
IL036117591Medicaid
ILCA4748OtherMEDICARE RAILROAD (GROUP)