Healthcare Provider Details

I. General information

NPI: 1275947962
Provider Name (Legal Business Name): DANA KOTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 08/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PFINGSTEN RD
GLENVIEW IL
60026-1301
US

IV. Provider business mailing address

2100 PFINGSTEN RD
GLENVIEW IL
60026-1301
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-5800
  • Fax:
Mailing address:
  • Phone: 847-657-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: