Provider Demographics
NPI:1548482359
Name:ROBERT S. KINSELLA, D.O.,S.C.
Entity type:Organization
Organization Name:ROBERT S. KINSELLA, D.O.,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:KINSELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-220-8460
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-0002
Mailing Address - Country:US
Mailing Address - Phone:815-220-8460
Mailing Address - Fax:815-220-8462
Practice Address - Street 1:1631 4TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-3507
Practice Address - Country:US
Practice Address - Phone:815-220-8460
Practice Address - Fax:815-220-8462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2016-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092375207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092375Medicaid
IL05032051OtherBLUE CROSS BLUE SHIELD
IL036092375Medicaid
IL212075Medicare PIN