Provider Demographics
NPI:1205883741
Name:KRAFT, JEROME P (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:P
Last Name:KRAFT
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 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-6644
Mailing Address - Fax:
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-6644
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141413OtherHEALTHLINK
IL4281670001OtherDME
IL009013OtherHEALTH ALLIANCE
IL7230175OtherBLUE CROSS BLUE SHIELD
IL20004076OtherRR MEDICARE
IL141413OtherHEALTHLINK
IL7230175OtherBLUE CROSS BLUE SHIELD