Basic Information
| Provider Information | |||||||||
| NPI: | 1942266549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBINSON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3043 | ||||||||
| Address2: | MEA AEA KENOSH SC | ||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307340200 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Practice Location | |||||||||
| Address1: | 10400 75TH ST | ||||||||
| Address2: | AURORA MEDICAL CENTER | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626977000 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 39518020 | WI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32426800 | 05 | WI | MEDICAID |