Provider Demographics
NPI:1669474870
Name:BOWERSOX, KEITH DAVID (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DAVID
Last Name:BOWERSOX
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 W 95TH ST STE 308
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2660
Mailing Address - Country:US
Mailing Address - Phone:708-346-4040
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 4005
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-593-4116
Practice Address - Fax:847-593-4135
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078229208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078229Medicaid
IL036078229Medicaid
ILR00262Medicare PIN
ILF400135587Medicare PIN
ILF400135591Medicare PIN