Basic Information
| Provider Information | |||||||||
| NPI: | 1710950100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTZAN | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 STRATHAM CIR | ||||||||
| Address2: | |||||||||
| City: | NORTH BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600106908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154557200 | ||||||||
| FaxNumber: | 8154559256 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E CONGRESS PARKWAY SUITE 250 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600146258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154557200 | ||||||||
| FaxNumber: | 8154559256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036076689 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036076689 | 05 | IL | MEDICAID | 5632272 | 01 | IL | BCBS | OTHER |