Active NPI
Kenneth J Liesen MD SC
- Family Medicine Physician
- St Charles, IL
National Provider Identifier
1124223763
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036077277
- Legal business name
- KENNETH J LIESEN MD SC
- Practice address
- 606 Riverside Ave
St Charles, IL 60174-2969 - Phone
- (630) 584-8900
- Fax
- (630) 584-2806
- NPI assigned
- Jun 15, 2007
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Kenneth J Liesen, MD
- Title
- Medical Doctor
- Phone
- (630) 584-8900
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036077277 | IL | Primary |
Addresses
Primary practice location
606 Riverside Ave
St Charles, IL 60174-2969
Mailing address
606 Riverside Ave
St Charles, IL 60174-2969
Phone (630) 584-8900
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036077277 | Medicaid | IL | |
| 966700 | Other | IL | INDIVIDUAL MEDICARE PTAN |
| 036077277 | Other | IL | BCBS |
| 943790 | Other | IL | GROUP PTAN |
National Provider Directory
National Provider DirectoryLocations
606 Riverside Ave
St Charles, IL 60174
Phone (630) 584-5920
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1181865600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1389916800000",
"number": "1124223763",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "606 RIVERSIDE AVE",
"city": "ST CHARLES",
"state": "IL",
"postal_code": "601742969",
"telephone_number": "630-584-8900",
"fax_number": "630-584-2806"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "606 RIVERSIDE AVE",
"city": "ST CHARLES",
"state": "IL",
"postal_code": "601742969",
"telephone_number": "630-584-8900",
"fax_number": "630-584-2806"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "KENNETH J LIESEN MD SC",
"organizational_subpart": "NO",
"enumeration_date": "2007-06-15",
"last_updated": "2014-01-17",
"status": "A",
"authorized_official_last_name": "LIESEN",
"authorized_official_first_name": "KENNETH",
"authorized_official_middle_name": "J",
"authorized_official_title_or_position": "MEDICAL DOCTOR",
"authorized_official_telephone_number": "630-584-8900",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Family Medicine",
"state": "IL",
"license": "036077277",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036077277",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "INDIVIDUAL MEDICARE PTAN",
"identifier": "966700",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "036077277",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "GROUP PTAN",
"identifier": "943790",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in St Charles, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 17, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.