William Blake Civiletta-Kalich, PA
Individual provider Active NPI Physician Assistant · Zion, IL
NPI 1386607356 · NPPES record last updated Oct 9, 2018
Key facts
- NPI
- 1386607356
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 085.003749 (IL)
- Practice address
- 2520 Elisha Avenue
Zion, IL 60099 - Phone
- (414) 325-7246
- Fax
- (414) 325-3770
- NPI assigned
- Apr 10, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 085.003749 | IL | MD | Physician Assistant |
| 1748023 | WI | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Advanced Pain Management SC | Past | Accepting new patients | |
| Advanced Healthcare SC | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 1748023 | WI | |
| Physician Assistant | 363A00000X | 085.003749 | IL | Yes |
Addresses
Primary practice location
2520 Elisha Avenue
Zion, IL 60099
Mailing address
2361 Paysphere Circle
Chicago, IL 60674
Phone (414) 325-7246
Other names
- William Blake Kalich
Other providers in Zion, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 9, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.