Provider Demographics
NPI:1609894526
Name:DARDIS, KEVIN J (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:DARDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29624 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6611
Practice Address - Fax:608-756-6177
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53250-21207P00000X
IL036090958207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090958 1Medicaid
ILP00959255DR7136OtherRR MEDICARE
WI1609894526OtherBCBSWI
WIDARDIKEVOtherMERCYCARE INSURANCE
WI1609894526Medicaid
WIP00767435CD3624OtherRR MEDICARE
G16070Medicare UPIN
WI1609894526Medicaid