Basic Information
| Provider Information | |||||||||
| NPI: | 1124446117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | KIN KAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 S. FIRST AVENUE | ||||||||
| Address2: | LOYOLA OUTPATIENT CENTER, 4300 | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082166006 | ||||||||
| FaxNumber: | 7082162683 | ||||||||
| Practice Location | |||||||||
| Address1: | 2160 S. FIRST AVENUE | ||||||||
| Address2: | LOYOLA OUTPATIENT CENTER, 4300 | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082166006 | ||||||||
| FaxNumber: | 7082162683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2014 | ||||||||
| LastUpdateDate: | 09/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125065913 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.