Provider Demographics
NPI:1861666299
Name:BRUCE KOLTON MD LLC
Entity Type:Organization
Organization Name:BRUCE KOLTON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-839-9999
Mailing Address - Street 1:21421 NETWORK PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-0001
Mailing Address - Country:US
Mailing Address - Phone:847-839-9999
Mailing Address - Fax:847-885-1111
Practice Address - Street 1:2500 W HIGGINS RD STE 940
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-2085
Practice Address - Country:US
Practice Address - Phone:847-839-9999
Practice Address - Fax:847-885-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360475801Medicaid
IL=========6001101Medicaid
IL0360475801Medicaid