Provider Demographics
NPI:1447313929
Name:KENNETH S STONE DPM
Entity type:Organization
Organization Name:KENNETH S STONE DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-235-4231
Mailing Address - Street 1:1717 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4695
Mailing Address - Country:US
Mailing Address - Phone:815-235-4231
Mailing Address - Fax:815-233-9531
Practice Address - Street 1:1717 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4695
Practice Address - Country:US
Practice Address - Phone:815-235-4231
Practice Address - Fax:815-233-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT39070Medicare UPIN
IL0428090001Medicare NSC