Basic Information
| Provider Information | |||||||||
| NPI: | 1477549889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLORENCE | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4440 W 95TH ST | ||||||||
| Address2: | EMG LAB, ROOM 042 SOUTH | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086845428 | ||||||||
| FaxNumber: | 7086842079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036101634 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 47626 | 01 | IL | ADVOCATE HLTH PARTNERS ID | OTHER | 250011628 | 01 | IL | RAILROAD MEDICARE | OTHER | 36354817310 | 01 | IL | ADVOCATE HLTH CENTERS ID | OTHER | 036101634 | 05 | IL | MEDICAID | 01621490 | 01 | IL | BCBS PROVIDER ID | OTHER |