Provider Demographics
NPI:1720195100
Name:KOCHMAN-SIMON, ELLEN R (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:R
Last Name:KOCHMAN-SIMON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:R
Other - Last Name:KOCHMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60121-1509
Mailing Address - Country:US
Mailing Address - Phone:224-238-4200
Mailing Address - Fax:847-783-0599
Practice Address - Street 1:1054 NORWOOD LN
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4556
Practice Address - Country:US
Practice Address - Phone:630-213-3232
Practice Address - Fax:630-213-3231
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064573207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31602727OtherBCBS OF IL
IL749331Medicare ID - Type Unspecified
ILP00854981Medicare PIN
IL31602727OtherBCBS OF IL
ILK53087Medicare PIN