Healthcare Provider Details

I. General information

NPI: 1851657449
Provider Name (Legal Business Name): ALLEN KODISH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2012
Last Update Date: 04/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E 53RD ST #802
CHICAGO IL
60615-4557
US

IV. Provider business mailing address

1525 E 53RD ST #802
CHICAGO IL
60615-4557
US

V. Phone/Fax

Practice location:
  • Phone: 312-332-2101
  • Fax: 773-324-8098
Mailing address:
  • Phone: 312-332-2101
  • Fax: 773-324-8098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number036057422
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: