Provider Demographics
NPI:1255351276
Name:ADAMS, KENNETH (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:ADAMS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-4240
Mailing Address - Fax:
Practice Address - Street 1:525 SWEETBRIAR DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:IL
Practice Address - Zip Code:61523
Practice Address - Country:US
Practice Address - Phone:309-274-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036071354363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL01R7OtherJOHN DEERE
IL970016346OtherMEDICARE RAILROAD
IL0360713543Medicaid
IL008863OtherHEALTH ALLIANCE
IL472299OtherHEALTHLINK
IL7215059OtherBCBS PPO
ILIL01R7OtherJOHN DEERE
IL970016346OtherMEDICARE RAILROAD