Provider Demographics
NPI:1952366551
Name:COHEN, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:COHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 N MICHIGAN AVE STE 822
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2879
Mailing Address - Country:US
Mailing Address - Phone:312-337-4404
Mailing Address - Fax:877-308-5358
Practice Address - Street 1:645 N MICHIGAN AVE
Practice Address - Street 2:SUITE 822
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-337-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-0721652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31602745OtherBLUECROSSBLUESHIELD PROVI
IL783620Medicare ID - Type Unspecified