Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 036.0771777 | IL |
Y | 111NI0900X | Internist | 036.0771777 | IL |
NPI | 1003173345 |
---|---|
Provider Name | Dr. Bruce Delozier Kenamore |
First Address | Wilmette, IL 60091-3402 |
Second Address | Wilmette, IL 60091-3402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2012 |
Last Update Date | 11/04/2012 |