Healthcare Provider Details

I. General information

NPI: 1467626184
Provider Name (Legal Business Name): NATHANIEL KOO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST SUITE 518-E
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

1012 N WOOD ST UNIT 2
CHICAGO IL
60622-3261
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-6765
  • Fax:
Mailing address:
  • Phone: 847-903-7507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036133774
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number036133774
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: