Provider Demographics
NPI:1457372724
Name:KENNEASTER, DEREK G (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:G
Last Name:KENNEASTER
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 1:220 N PARK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3150
Mailing Address - Country:US
Mailing Address - Phone:618-942-3344
Mailing Address - Fax:618-942-5045
Practice Address - Street 1:220 N PARK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3150
Practice Address - Country:US
Practice Address - Phone:618-942-3344
Practice Address - Fax:618-942-5045
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94334207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093018Medicaid
10007459OtherBCBS
65958OtherMEDICARE PTAN
FL31057OtherBCBS
FL31057OtherBCBS
FLU6145YMedicare ID - Type Unspecified
IL036093018Medicaid