Healthcare Provider Details

I. General information

NPI: 1235797929
Provider Name (Legal Business Name): HALEY MARIE KOTH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16660 107TH ST
ORLAND PARK IL
60467-8898
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 708-403-8500
  • Fax: 708-364-7080
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-158134
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: