Provider Demographics
NPI:1619971157
Name:KOZENY, KEITH MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MICHAEL
Last Name:KOZENY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W LAKE COOK RD
Mailing Address - Street 2:STE 110
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2089
Mailing Address - Country:US
Mailing Address - Phone:847-459-6611
Mailing Address - Fax:847-459-7929
Practice Address - Street 1:600 W LAKE COOK RD
Practice Address - Street 2:STE 110
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2089
Practice Address - Country:US
Practice Address - Phone:847-459-6611
Practice Address - Fax:847-459-7929
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073084207NS0135X, 207N00000X, 207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILB54301Medicare UPIN
IL31601993OtherBCBS OF IL PROVIDER NUMBE
ILK21895Medicare PIN
IL212426OtherMEDICARE GROUP PRAC ID
IL4075229OtherAETNA PROVIDER NUMBER