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Individual provider Active NPI

Kenrick L Roberts, PHYSICIAN ASSISTANT

  • Physician Assistant
  • Evergreen Park, IL
National Provider Identifier
1265754329
Registry record updated Apr 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
085-003520 Issued in IL
Practice address
2850 W 95TH St
Suite 301
Evergreen Park, IL 60805-2735
Phone
(708) 389-2200
NPI assigned
Feb 17, 2010
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 29, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 085003520 IL
Surgical Physician Assistant 363AS0400X 085003520 IL
Physician Assistant 363A00000X 085-003520 IL Primary

Addresses

Primary practice location

2850 W 95TH St
Suite 301
Evergreen Park, IL 60805-2735

Mailing address

PO Box 26975
Jacksonville, FL 32226-6975
Phone (773) 450-5709

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address kenrick.roberts@direct.ccprovider.org Direct Cook County

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20110428000590 IL Practitioner - Physician Assistant 8820273212 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2008
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Cook CountyGroup PAC ID 2860398088, 770 clinicians

Practice addresses (Care Compare)

500 E 51St St
Chicago, IL 60615-2494
Phone (312) 572-2000

Hospital & facility affiliations

  • John H Stroger Jr Hospital Hospital, Chicago, IL, CCN 140124

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
085-003520ILMDPhysician Assistant
085003520ILMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Cook County CurrentSince Apr 30, 2020 Accepting new patients
Cook County CurrentSince Apr 30, 2020 Accepting new patients
John H Stroger Jr Hospital Cook County Past Accepting new patients
Advocate Health Centers, Inc. Past Accepting new patients

Locations

6337 S Woodlawn Ave
Chicago, IL 60637
Phone (312) 747-0059

500 E 51st St
Chicago, IL 60615
Phone (312) 572-2000

1969 W Ogden Ave
Chicago, IL 60612
Phone (312) 864-3600

1901 W Harrison St
Chicago, IL 60612
Phone (312) 864-5100

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 27

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 27

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1266364800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1619654400000",
    "number": "1265754329",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 26975",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322266975",
            "telephone_number": "773-450-5709"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2850 W 95TH ST",
            "address_2": "SUITE 301",
            "city": "EVERGREEN PARK",
            "state": "IL",
            "postal_code": "608052735",
            "telephone_number": "708-389-2200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROBERTS",
        "first_name": "KENRICK",
        "middle_name": "L",
        "credential": "PHYSICIAN ASSISTANT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-02-17",
        "last_updated": "2021-04-29",
        "certification_date": "2021-04-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "IL",
            "license": "085003520",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "IL",
            "license": "085003520",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085-003520",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kenrick.roberts@direct.ccprovider.org",
            "affiliation": "Y",
            "affiliationName": "Cook County",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "1969 W. Ogden Ave.",
            "city": "Chicago",
            "state": "IL",
            "country_code": "US",
            "postal_code": "606123723",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Evergreen Park, IL

Sources for this page

Verify at the official NPI Registry.