Healthcare Provider Details

I. General information

NPI: 1255568333
Provider Name (Legal Business Name): KENNY BOZORGI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W HURON ST SUITE 301
CHICAGO IL
60654-3431
US

IV. Provider business mailing address

409 W HURON ST SUITE 301
CHICAGO IL
60654-3431
US

V. Phone/Fax

Practice location:
  • Phone: 312-787-7861
  • Fax: 312-787-7916
Mailing address:
  • Phone: 312-787-7861
  • Fax: 312-787-7916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number036090621
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: