Active NPI
Kenneth William Park, D.O.
- Family Medicine Physician
- Cary, IL
National Provider Identifier
1114928801
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036055468
- Practice address
- 125 Carlisle CT
Cary, IL 60013-1908 - Phone
- (847) 639-1685
- NPI assigned
- Aug 3, 2005
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036055468 | IL | Primary |
Addresses
Primary practice location
125 Carlisle CT
Cary, IL 60013-1908
Mailing address
125 Carlisle CT
Cary, IL 60013-1908
Phone (847) 639-1685
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 036055468 | IL | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1123027200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1250121600000",
"number": "1114928801",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "125 CARLISLE CT",
"city": "CARY",
"state": "IL",
"postal_code": "600131908",
"telephone_number": "847-639-1685"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "125 CARLISLE CT",
"city": "CARY",
"state": "IL",
"postal_code": "600131908",
"telephone_number": "847-639-1685"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PARK",
"first_name": "KENNETH",
"middle_name": "WILLIAM",
"name_prefix": "Dr.",
"credential": "D.O.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-08-03",
"last_updated": "2009-08-13",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036055468",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Cary, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.