Provider Demographics
NPI:1821032723
Name:KORTAN, RICHARD ROBERT SR (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ROBERT
Last Name:KORTAN
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073
Mailing Address - Country:US
Mailing Address - Phone:847-740-1100
Mailing Address - Fax:847-740-1100
Practice Address - Street 1:702 ROLLINS RD
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073
Practice Address - Country:US
Practice Address - Phone:847-740-1100
Practice Address - Fax:847-740-1100
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL994800Medicare ID - Type Unspecified