Provider Demographics
NPI:1134177728
Name:KANNEL, PHILIP D (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:D
Last Name:KANNEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SAINT ANTHONYS WAY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-462-2277
Mailing Address - Fax:618-463-9342
Practice Address - Street 1:2 SAINT ANTHONYS WAY
Practice Address - Street 2:SUITE 305
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-462-2277
Practice Address - Fax:618-463-9342
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067336207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067336Medicaid
IL040016118Medicare PIN
IL701510Medicare ID - Type Unspecified
C45856Medicare UPIN
MO937434803Medicare PIN
IL384230008Medicare PIN