Provider Demographics
NPI:1992758965
Name:KOEHN, GARY L (MD, PHD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:KOEHN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-482-4500
Mailing Address - Fax:708-482-4502
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-482-4500
Practice Address - Fax:708-482-4502
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25969207L00000X
IL036074138207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL030038OtherHEALTH ALLIANCE ID
IL01608719OtherBLUE CROSS PROVIDER NO.
IL132321800OtherUS DEPT OF LABOR GROUP
IL1164451308OtherGL KOEHN ASSOC GROUP NPI
IL01608719OtherBLUE CROSS PROVIDER NO.
ILK15231Medicare ID - Type UnspecifiedINDIVIDUAL ID LOC 16(COOK
IL030038OtherHEALTH ALLIANCE ID
IL132321800OtherUS DEPT OF LABOR GROUP
ILK28562Medicare ID - Type UnspecifiedMC INDIVIDUAL PROVIDER #
ILK15232Medicare ID - Type UnspecifiedINDIV ID LOCAL 99