Basic Information
| Provider Information | |||||||||
| NPI: | 1902891674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUMMERER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | GERARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 BORMET DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464040 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 GARFIELD AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600484723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479905636 | ||||||||
| FaxNumber: | 8473671535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036087848 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208G00000X | 55253-20 | WI | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 036087848 | IL | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208600000X | 036087848 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 55253-20 | WI | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200269890B | 05 | IN | MEDICAID | 036087848 | 05 | IL | MEDICAID | 200269890A | 05 | IN | MEDICAID | 01618941 | 01 | IL | BCBS | OTHER | 1902891674 | 05 | WI | MEDICAID |