Provider Demographics
NPI:1003927013
Name:HANDY, KENNETH GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GEORGE
Last Name:HANDY
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 1:400 NORTH WALL ST
Mailing Address - Street 2:STE 504
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2965
Mailing Address - Country:US
Mailing Address - Phone:815-932-4021
Mailing Address - Fax:815-932-7270
Practice Address - Street 1:400 NORTH WALL ST
Practice Address - Street 2:STE 504
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2965
Practice Address - Country:US
Practice Address - Phone:815-932-4021
Practice Address - Fax:815-932-7270
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068557Medicaid
D15435Medicare UPIN
IL036068557Medicaid