Provider Demographics
NPI:1750517488
Name:KERN, DUSTIN
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:KERN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 N STATE ROUTE 91
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9541
Mailing Address - Country:US
Mailing Address - Phone:309-692-5394
Mailing Address - Fax:309-692-2272
Practice Address - Street 1:8600 N STATE ROUTE 91
Practice Address - Street 2:SUITE 250
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9541
Practice Address - Country:US
Practice Address - Phone:309-692-5394
Practice Address - Fax:309-692-2272
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-339058390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGOtherMEDICARE