Basic Information
| Provider Information | |||||||||
| NPI: | 1982785572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 21-100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126950990 | ||||||||
| FaxNumber: | 3126951106 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 21-100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126950990 | ||||||||
| FaxNumber: | 3126951106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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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 | 363A00000X | PA04678 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 085.006901 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00677105 | 01 | TX | RR MEDICARE | OTHER | 8Y0727 | 01 | TX | BCBS | OTHER | 184834301 | 05 | TX | MEDICAID |