Organization
KENILWORTH MEDICAL ASSOCIATES, S.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PAUL DETJEN MD (PRESIDENT)
(847) 256-5505
Entity
Organization
Contact information
Practice address
534 GREEN BAY RD, KENILWORTH, IL 60043-1801
(847) 256-5505
(847) 256-5567
Mailing address
534 GREEN BAY RD, KENILWORTH, IL 60043-1801
(847) 256-5505
(847) 256-5567
Taxonomy
Speciality
Code
Description
License number
State
207K00000X
Allergy & Immunology Physician
Primary
036072795
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036072795
—
IL
Enumeration date
02/28/2007
Last updated
11/20/2014
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