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Organization
KENNETH J LIESEN MD SC
Active
Organization
KENNETH J LIESEN MD SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH J LIESEN MD (MEDICAL DOCTOR)
(630) 584-8900
Entity
Organization
Contact information
Practice address
606 RIVERSIDE AVE, ST CHARLES, IL 60174-2969
(630) 584-8900
(630) 584-2806
Mailing address
606 RIVERSIDE AVE, ST CHARLES, IL 60174-2969
(630) 584-8900
(630) 584-2806
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036077277
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036077277
BCBS
IL
05
—
036077277
—
IL
01
—
943790
GROUP PTAN
IL
01
—
966700
INDIVIDUAL MEDICARE PTAN
IL
Enumeration date
06/15/2007
Last updated
01/17/2014
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