Basic Information
| Provider Information | |||||||||
| NPI: | 1457603557 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROL KOTZAN MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600147978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154557200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600147978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154557200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 03/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | KOTZAN | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8154557200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036076689 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036076689 | 05 | IL | MEDICAID | 5632584 | 01 | IL | BCBS | OTHER |