Provider Demographics
NPI:1710379631
Name:COYNE, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:COYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 14-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5966
Mailing Address - Country:US
Mailing Address - Phone:312-695-7970
Mailing Address - Fax:312-695-4433
Practice Address - Street 1:675 N SAINT CLAIR ST STE 14-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5966
Practice Address - Country:US
Practice Address - Phone:312-695-7970
Practice Address - Fax:312-695-4433
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036152351207RE0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program