Provider Demographics
NPI:1033102702
Name:KONZEN, KEVIN L (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:KONZEN
Suffix:
Gender:
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:PO BOX 7412037
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2037
Mailing Address - Country:US
Mailing Address - Phone:314-333-4100
Mailing Address - Fax:314-333-4115
Practice Address - Street 1:4320 FOREST PARK AVE
Practice Address - Street 2:STE 1100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2979
Practice Address - Country:US
Practice Address - Phone:314-333-4100
Practice Address - Fax:314-333-4115
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104494207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208096214Medicaid
K11156Medicare ID - Type Unspecified
IL036075200Medicaid