Basic Information
| Provider Information | |||||||||
| NPI: | 1770563710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETTERLING | ||||||||
| FirstName: | KEVAN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 KANEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305841400 | ||||||||
| FaxNumber: | 6305841733 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 KANEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305841400 | ||||||||
| FaxNumber: | 6305841733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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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 | 207X00000X | 36082353 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 036082353 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 141081 | 01 | IL | MEDICARE FACILITY | OTHER | CF2064 | 01 | IL | RAILROAD GROUP | OTHER | 200007873 | 01 | IL | RAILROAD MEDICARE | OTHER | 036082353 | 05 | IL | MEDICAID |