Healthcare Provider Details

I. General information

NPI: 1750794947
Provider Name (Legal Business Name): JUSTIN CHARLES KOHL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N OAK ST
HINSDALE IL
60521-3860
US

IV. Provider business mailing address

135 N OAK ST
HINSDALE IL
60521-3860
US

V. Phone/Fax

Practice location:
  • Phone: 630-856-8900
  • Fax: 630-856-8933
Mailing address:
  • Phone: 630-856-8900
  • Fax: 630-856-8933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125064934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: