Basic Information
| Provider Information | |||||||||
| NPI: | 1619092095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LADENDORF | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 WARRENVILLE ROAD | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303247911 | ||||||||
| FaxNumber: | 6303247942 | ||||||||
| Practice Location | |||||||||
| Address1: | 7447 W TALCOTT AVENUE | ||||||||
| Address2: | SUITE 512 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477881553 | ||||||||
| FaxNumber: | 7735778187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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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 | 363AS0400X | 085-002545 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 085002545 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.