Provider Demographics
NPI:1174529556
Name:EAKIN, KENNETH MAX (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MAX
Last Name:EAKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 JUNCTION DR W
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2916
Mailing Address - Country:US
Mailing Address - Phone:618-288-5088
Mailing Address - Fax:618-288-9153
Practice Address - Street 1:3 JUNCTION DR W
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2916
Practice Address - Country:US
Practice Address - Phone:618-288-5088
Practice Address - Fax:618-288-9153
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080021116OtherRR MEDICARE
0107335OtherUNITED HEALTHCARE
371205888OtherTAX ID
118802OtherHEALTHLINK
N4882OtherGROUP HEALTH PLAN
IL036066196Medicaid
IL4622029OtherADMINISTAR
371205888OtherTAX ID
IL080021116OtherRR MEDICARE