Basic Information
| Provider Information | |||||||||
| NPI: | 1629457163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAROLD | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE. | ||||||||
| Address2: | PEDIATRIC HOSPITALISTS | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701027 | ||||||||
| FaxNumber: | 8477335108 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE. | ||||||||
| Address2: | PEDIATRIC HOSPITALISTS | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701027 | ||||||||
| FaxNumber: | 8477335108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036145743 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 2021010362 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 2021010362 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208M00000X | 2021010362 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 036145743 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200098528 | 05 | MO | MEDICAID |