Provider Demographics
NPI:1932480605
Name:KISHWAUKEE PHYSICIAN GROUP INC
Entity Type:Organization
Organization Name:KISHWAUKEE PHYSICIAN GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZYDEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-748-2986
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-0487
Mailing Address - Country:US
Mailing Address - Phone:815-756-1521
Mailing Address - Fax:
Practice Address - Street 1:1 KISH HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9602
Practice Address - Country:US
Practice Address - Phone:815-756-1521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty