Individual
DEREK G KENNEASTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
220 N PARK AVE, SUITE 2, HERRIN, IL 62948-3150
(618) 942-3344
(618) 942-5045
Mailing address
220 N PARK AVE, SUITE 2, HERRIN, IL 62948-3150
(618) 942-3344
(618) 942-5045
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
ME94334
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036093018
—
IL
01
—
10007459
BCBS
—
01
—
31057
BCBS
FL
01
—
65958
MEDICARE PTAN
—
Enumeration date
07/22/2006
Last updated
03/23/2011
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