Basic Information
Provider Information | |||||||||
NPI: | 1285612259 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEBER | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
Address2: | #240 | ||||||||
City: | WESTCHESTER | ||||||||
State: | IL | ||||||||
PostalCode: | 601545701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1611 W. HARRISON | ||||||||
Address2: | SUITE 400 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3124313400 | ||||||||
FaxNumber: | 3129421517 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2006 | ||||||||
LastUpdateDate: | 11/20/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0010X | 036099936 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 7785085 | 01 | IL | AETNA ID# | OTHER | 036099936 2 | 05 | IL |   | MEDICAID | 207067 | 01 | IL | MEDICARE PTIN LOCALITY 16 | OTHER | 207073 | 01 | IL | MEDICARE PTAN LOCALITY 15 | OTHER | DA4902 | 01 | IL | RR MEDICARE PTAN # | OTHER | P00091153 | 01 | IL | RR MEDICARE ID# | OTHER | 1633878 | 01 | IL | BCBS GROUP # | OTHER |