Healthcare Provider Details

I. General information

NPI: 1013578475
Provider Name (Legal Business Name): DR. KEVIN BOUBOULEIX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

2108 N WINCHESTER AVE # 3
CHICAGO IL
60614-3915
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 847-542-2688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125074524
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: