Basic Information
| Provider Information | |||||||||
| NPI: | 1346493400 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EKSTROM | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PIERCY | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506879 | ||||||||
| FaxNumber: | 2703893707 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 MERRITT DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424202788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708270064 | ||||||||
| FaxNumber: | 2708263338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2008 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7471451-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 47919 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 7471451-1205 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 47919 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100345240 | 05 | KY | MEDICAID |