Basic Information
| Provider Information | |||||||||
| NPI: | 1225118128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TREVIRANUS | ||||||||
| FirstName: | KIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E MILLER RD | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610811252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156254790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 E MILLER RD | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610811252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156254790 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | 036061910 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9815737 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 091400 | 01 | IL | HEALTH ALLIANCE MEDICAL | OTHER | 036061910 | 05 | IL | MEDICAID |