Provider Demographics
NPI:1366548810
Name:KEN HODEL M D GYNONC S C
Entity type:Organization
Organization Name:KEN HODEL M D GYNONC S C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-683-8910
Mailing Address - Street 1:6915 N KNOXVILLE AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2850
Mailing Address - Country:US
Mailing Address - Phone:309-683-8910
Mailing Address - Fax:309-683-8911
Practice Address - Street 1:6915 N KNOXVILLE AVE
Practice Address - Street 2:STE 1
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2850
Practice Address - Country:US
Practice Address - Phone:309-683-8910
Practice Address - Fax:309-683-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA24511Medicare UPIN
213978Medicare PIN