Provider Demographics
NPI:1902891674
Name:KUMMERER, ROBERT GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GERARD
Last Name:KUMMERER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 BORMET DR STE 204
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8399
Mailing Address - Country:US
Mailing Address - Phone:708-346-4040
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:890 GARFIELD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-4723
Practice Address - Country:US
Practice Address - Phone:847-990-5636
Practice Address - Fax:847-367-1535
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360878482086S0129X, 208G00000X, 208600000X
WI55253-20208G00000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200269890BMedicaid
IL036087848Medicaid
IN200269890AMedicaid
IL01618941OtherBCBS
WI1902891674Medicaid
WIWI2609007Medicare PIN
IL01618941OtherBCBS
IN200269890BMedicaid
ILG70456Medicare UPIN
IL709940Medicare PIN
IN200269890AMedicaid
IL780002079Medicare PIN
WI1902891674Medicaid
ILL87112Medicare PIN