Provider Demographics
NPI:1720264898
Name:CARSON, KENNETH ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:CARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5970
Mailing Address - Country:US
Mailing Address - Phone:312-695-6180
Mailing Address - Fax:312-695-1106
Practice Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5970
Practice Address - Country:US
Practice Address - Phone:312-695-6180
Practice Address - Fax:312-695-1106
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008016004207RH0003X
IL036111759207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology