Basic Information
Provider Information | |||||||||
NPI: | 1336243815 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REDLICH | ||||||||
FirstName: | KRISTI | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EGLAND | ||||||||
OtherFirstName: | KRISTI | ||||||||
OtherMiddleName: | N | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 10350 HALIGUS RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | HUNTLEY | ||||||||
State: | IL | ||||||||
PostalCode: | 601429545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153386600 | ||||||||
FaxNumber: | 8478027200 | ||||||||
Practice Location | |||||||||
Address1: | 10350 HALIGUS RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | HUNTLEY | ||||||||
State: | IL | ||||||||
PostalCode: | 60142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8153386600 | ||||||||
FaxNumber: | 8478027200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2006 | ||||||||
LastUpdateDate: | 10/19/2018 | ||||||||
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 | 208000000X | 036115247 | IL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 036115247 | 01 | IL | STATE LICENSE | OTHER |