| Kenneth J Liesen Md Sc | |
|
606 Riverside Ave St Charles IL 60174-2969 | |
| (630) 584-8900 | |
| (630) 584-2806 |
| Full Name | Kenneth J Liesen Md Sc |
|---|---|
| Speciality | Family Medicine |
| Location | 606 Riverside Ave, St Charles, Illinois |
| Authorized Official Name and Position | Kenneth J Liesen (MEDICAL DOCTOR) |
| Authorized Official Contact | 6305848900 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Kenneth J Liesen Md Sc 606 Riverside Ave St Charles IL 60174-2969 Ph: (630) 584-8900 | Kenneth J Liesen Md Sc 606 Riverside Ave St Charles IL 60174-2969 Ph: (630) 584-8900 |
| NPI Number | 1124223763 |
|---|---|
| Provider Enumeration Date | 06/15/2007 |
| Last Update Date | 01/17/2014 |
| Medicare PECOS PAC ID | 7618157850 |
|---|---|
| Medicare Enrollment ID | O20110205000079 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124223763 | NPI | - | NPPES |
| 036077277 | Medicaid | IL | |
| 966700 | Other | IL | INDIVIDUAL MEDICARE PTAN |
| 036077277 | Other | IL | BCBS |
| 943790 | Other | IL | GROUP PTAN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 036077277 (Illinois) | Primary |
| Provider Name | Kenneth J Liesen |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1699896498 PECOS PAC ID: 3072793215 Enrollment ID: I20110205000088 |
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