Active NPI
Kenneth Max Eakin, M.D.
- Family Medicine Physician
- Glen Carbon, IL
National Provider Identifier
1174529556
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036066196
- Practice address
- 3 Junction Dr W
Glen Carbon, IL 62034-2916 - Phone
- (618) 288-5088
- Fax
- (618) 288-9153
- NPI assigned
- Jun 22, 2005
- Last updated
- Apr 30, 2008
- Sex
- Male
- Sole proprietor
- No
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 | 036066196 | IL | Primary |
Addresses
Primary practice location
3 Junction Dr W
Glen Carbon, IL 62034-2916
Mailing address
3 Junction Dr W
Glen Carbon, IL 62034-2916
Phone (618) 288-5088
Other identifiers 7
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 080021116 | Other | IL | RR MEDICARE |
| 0107335 | Other | UNITED HEALTHCARE | |
| 371205888 | Other | TAX ID | |
| 118802 | Other | HEALTHLINK | |
| N4882 | Other | GROUP HEALTH PLAN | |
| 036066196 | Medicaid | IL | |
| 4622029 | Other | IL | ADMINISTAR |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1119398400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1209513600000",
"number": "1174529556",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3 JUNCTION DR W",
"city": "GLEN CARBON",
"state": "IL",
"postal_code": "620342916",
"telephone_number": "618-288-5088",
"fax_number": "618-288-9153"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3 JUNCTION DR W",
"city": "GLEN CARBON",
"state": "IL",
"postal_code": "620342916",
"telephone_number": "618-288-5088",
"fax_number": "618-288-9153"
}
],
"practiceLocations": [],
"basic": {
"last_name": "EAKIN",
"first_name": "KENNETH",
"middle_name": "MAX",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-06-22",
"last_updated": "2008-04-30",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036066196",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RR MEDICARE",
"identifier": "080021116",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED HEALTHCARE",
"identifier": "0107335",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TAX ID",
"identifier": "371205888",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HEALTHLINK",
"identifier": "118802",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "GROUP HEALTH PLAN",
"identifier": "N4882",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036066196",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ADMINISTAR",
"identifier": "4622029",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Glen Carbon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 30, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.