Provider Demographics
NPI:1699840157
Name:ELENA KOLES, M.D.
Entity Type:Organization
Organization Name:ELENA KOLES, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PH D
Authorized Official - Phone:847-219-0900
Mailing Address - Street 1:666 DUNDEE RD STE 602
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2733
Mailing Address - Country:US
Mailing Address - Phone:847-291-0900
Mailing Address - Fax:
Practice Address - Street 1:666 DUNDEE RD STE 602
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2733
Practice Address - Country:US
Practice Address - Phone:847-291-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095112207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095112Medicaid
IL211594Medicare ID - Type Unspecified
IL036095112Medicaid