Individual
ERIC A KIVISTO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1405 E 12TH ST, SUITE 500, MENDOTA, IL 61342-9010
(815) 539-1789
(815) 539-1430
Mailing address
1401 E 12TH ST, MENDOTA, IL 61342-9216
(815) 539-1789
(815) 539-1430
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
036091073
IL
208600000X
Surgery Physician
5101011210
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
02706617
BLUE CROSS/BLUE SHIELD
IL
05
—
036091073
—
IL
01
—
371342699
FEIN NUMBER
IL
Enumeration date
07/06/2005
Last updated
12/07/2022
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