Healthcare Provider Details

I. General information

NPI: 1245447416
Provider Name (Legal Business Name): KIMBERLY A CZECH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 2E MEDICAL STAFF OFFICE
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

840 S WOOD ST # MC856
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-9291
  • Fax: 312-355-4738
Mailing address:
  • Phone: 312-996-9291
  • Fax: 312-355-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number036128744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: