Healthcare Provider Details

I. General information

NPI: 1619971157
Provider Name (Legal Business Name): KEITH MICHAEL KOZENY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W LAKE COOK RD STE 110
BUFFALO GROVE IL
60089-2089
US

IV. Provider business mailing address

600 W LAKE COOK RD STE 110
BUFFALO GROVE IL
60089-2089
US

V. Phone/Fax

Practice location:
  • Phone: 847-459-6611
  • Fax: 847-459-7929
Mailing address:
  • Phone: 847-459-6611
  • Fax: 847-459-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036073084
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036073084
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number036073084
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: