Provider Demographics
NPI:1366488033
Name:MCKENZIE, TERESA (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:MCKENZIE-LANDGREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7605 1/2 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1133
Mailing Address - Country:US
Mailing Address - Phone:708-366-4888
Mailing Address - Fax:708-366-7510
Practice Address - Street 1:7605 1/2 NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1133
Practice Address - Country:US
Practice Address - Phone:708-366-4888
Practice Address - Fax:708-366-7510
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208524OtherMEDICARE
IL1639941OtherBCBS
IL036076673Medicaid
IL1639941OtherBCBS