Kenneth Craig Micetich, MD

Primary specialty

Hematology & Oncology PhysicianTaxonomy code 207RH0003X

License

36056032 Issued in IL

Practice address

2160 S 1St Ave
(15750 Marion Dr., Homer Glen, Il. 60491)
Maywood, IL 60153-3328

Phone

(708) 645-3400

Fax

(708) 645-3411

NPI assigned

Dec 30, 2005

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kmicetich13133@direct.luhs.org

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.

• Loyola University Medical Center

  • General Acute Care Hospital
  • Maywood, IL
  • NPI 1376521575
  NPD
• Loyola University Physician Foundation

  • General Practice Physician
  • Maywood, IL
  • NPI 1235148891
  NPD (past)

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

{
    "created_epoch": "1135900800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1262736000000",
    "number": "1619954583",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2160 S 1ST AVE",
            "address_2": "(15750 MARION DR., HOMER GLEN, IL. 60491)",
            "city": "MAYWOOD",
            "state": "IL",
            "postal_code": "601533328",
            "telephone_number": "708-645-3400",
            "fax_number": "708-645-3411"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2160 S 1ST AVE",
            "address_2": "(15750 MARION DR., HOMER GLEN, IL. 60491)",
            "city": "MAYWOOD",
            "state": "IL",
            "postal_code": "601533328",
            "telephone_number": "708-645-3400",
            "fax_number": "708-645-3411"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MICETICH",
        "first_name": "KENNETH",
        "middle_name": "CRAIG",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-12-30",
        "last_updated": "2010-01-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RH0003X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Hematology & Oncology",
            "state": "IL",
            "license": "36056032",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "36056032",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sydni Meunier
• Macy Lin Meyer, MD
• McKay Meyer
• Meredith Beth Meyer, MD
• Farukh Saeed Mian, M.D.
• Aaron Michelfelder, MD
• Marco Mikhael, M.D.
• Ellen Milad, APRN
• Hannah Catherine Milad, MD
• Alex Christopher Miller, MD

• Hematology & Oncology Physician in Maywood, IL
• Providers in Maywood, IL by specialty
• Hematology & Oncology Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2010; 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.

Verify at the official NPI Registry.