MEDICARE: DR. KEITH DAVID BOWERSOX M.D, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	036078229	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669474870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH DAVID BOWERSOX M.D, PHD

Provider Business Mailing Address
First Line	:	4400 W 95TH ST STE 308
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-2660
Country	:	US
Telephone Number	:	708-346-4040
Fax Number	:	708-346-3287

Provider Business Practice Location Address
First Line	:	800 BIESTERFIELD RD
Second Line	:	SUITE 4005
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3361
Country	:	US
Telephone Number	:	847-593-4116
Fax Number	:	847-593-4135

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	12/15/2021

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Directions to “ DR. KEITH DAVID BOWERSOX M.D, PHD” Practice Location

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