Provider Demographics
NPI:1316085897
Name:STEIN, KELLY BRUNGARDT (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BRUNGARDT
Last Name:STEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:MICHELLE
Other - Last Name:BRUNGARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9701 KNOX AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1256
Mailing Address - Country:US
Mailing Address - Phone:847-676-1112
Mailing Address - Fax:
Practice Address - Street 1:9701 KNOX AVE
Practice Address - Street 2:STE 102
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1256
Practice Address - Country:US
Practice Address - Phone:847-676-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0064374207R00000X
IL036126038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine