Provider Demographics
NPI:1265411987
Name:KERRY PANOZZO MD PC
Entity type:Organization
Organization Name:KERRY PANOZZO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:PANOZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-762-9711
Mailing Address - Street 1:4110 BLACKHAWK RD STE 2
Mailing Address - Street 2:SUITE #2
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7039
Mailing Address - Country:US
Mailing Address - Phone:309-428-7055
Mailing Address - Fax:309-265-0118
Practice Address - Street 1:4110 BLACKHAWK RD STE 2
Practice Address - Street 2:SUITE #2
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7039
Practice Address - Country:US
Practice Address - Phone:309-428-7055
Practice Address - Fax:309-265-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090677207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0535666Medicaid
IA1535666Medicaid
IA1535666Medicaid
IAI9903Medicare PIN