Provider Demographics
NPI:1366500639
Name:BOTSOE, KAREN K (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:K
Last Name:BOTSOE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:KERR
Other - Last Name:BOTSOE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9000 S STONY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3508
Mailing Address - Country:US
Mailing Address - Phone:773-731-0670
Mailing Address - Fax:
Practice Address - Street 1:9000 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3508
Practice Address - Country:US
Practice Address - Phone:773-731-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 118025207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA1490OtherRRMC
208342OtherGROUP PTAN MEDICARE
11BDWMBMedicare ID - Type Unspecified
DA1490OtherRRMC