Individual
KENNETH CRAIG MICETICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2160 S 1ST AVE, (15750 MARION DR., HOMER GLEN, IL. 60491), MAYWOOD, IL 60153-3328
(708) 645-3400
(708) 645-3411
Mailing address
2160 S 1ST AVE, (15750 MARION DR., HOMER GLEN, IL. 60491), MAYWOOD, IL 60153-3328
(708) 645-3400
(708) 645-3411
Taxonomy
Speciality
Code
Description
License number
State
207RH0003X
Hematology & Oncology Physician
Primary
36056032
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
36056032
—
IL
Enumeration date
12/30/2005
Last updated
01/06/2010
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