Provider Demographics
NPI:1871754168
Name:TERESA MCKENZIE, M.D., LLC
Entity type:Organization
Organization Name:TERESA MCKENZIE, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-366-4888
Mailing Address - Street 1:7605 1/2 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1133
Mailing Address - Country:US
Mailing Address - Phone:708-366-4888
Mailing Address - Fax:
Practice Address - Street 1:7605 1/2 NORTH AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1133
Practice Address - Country:US
Practice Address - Phone:708-366-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076673207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208524OtherMEDICARE
IL1639941OtherBCBS
IL036076673Medicaid
IL036076673Medicaid