Provider Demographics
NPI:1942492772
Name:CAROL A. KOTZAN, M.D., S. C.
Entity Type:Organization
Organization Name:CAROL A. KOTZAN, M.D., S. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KOTZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-455-7200
Mailing Address - Street 1:360 STATION DRVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7978
Mailing Address - Country:US
Mailing Address - Phone:815-455-7200
Mailing Address - Fax:815-455-9256
Practice Address - Street 1:5911 NORTHWEST HWY
Practice Address - Street 2:SUITE 105
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8065
Practice Address - Country:US
Practice Address - Phone:815-455-7200
Practice Address - Fax:815-455-9256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042617706207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202118Medicare PIN
IL202107Medicare PIN