Provider Demographics
NPI:1922180330
Name:NAM, KEITH K (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:K
Last Name:NAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEY
Other - Middle Name:LLTH
Other - Last Name:NAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3434 W PETERSON AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3319
Mailing Address - Country:US
Mailing Address - Phone:773-267-0781
Mailing Address - Fax:773-267-0968
Practice Address - Street 1:3434 W PETERSON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3319
Practice Address - Country:US
Practice Address - Phone:773-267-0781
Practice Address - Fax:773-267-0968
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036043256207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21603529OtherBS
IL036043256Medicaid
IL036043256Medicaid
IL468221Medicare PIN