Provider Demographics
NPI:1396701009
Name:KAIROUZ, SEBASTIEN SIMON (MD)
Entity type:Individual
Prefix:
First Name:SEBASTIEN
Middle Name:SIMON
Last Name:KAIROUZ
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 1:210 W MCKINLEY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-5858
Mailing Address - Country:US
Mailing Address - Phone:217-877-9442
Mailing Address - Fax:217-233-1670
Practice Address - Street 1:210 W MCKINLEY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-5858
Practice Address - Country:US
Practice Address - Phone:217-877-9442
Practice Address - Fax:217-233-1670
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067931207RH0003X
IL036128725207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218702700Medicaid
MD218702700Medicaid
005561608Medicare ID - Type Unspecified