Basic Information
| Provider Information | |||||||||
| NPI: | 1598705196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUZ | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | Q | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 WEST RTE 22 | ||||||||
| Address2: | SUITE 50 | ||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663440543 | ||||||||
| FaxNumber: | 8663443934 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W CENTRAL RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600052349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006552656 | ||||||||
| FaxNumber: | 4128227411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A90441 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | A90441 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A904410 | 01 | CA | BLUE SHIELD OF CA | OTHER | 00A904410 | 05 | CA | MEDICAID |