Healthcare Provider Details

I. General information

NPI: 1184884967
Provider Name (Legal Business Name): LARRY KENNETH KOCIOLEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2008
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE # 20
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4080
  • Fax:
Mailing address:
  • Phone: 312-227-4080
  • Fax: 312-227-9709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125051580
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: