Basic Information
| Provider Information | |||||||||
| NPI: | 1790102788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSSOW | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NEELY | ||||||||
| OtherFirstName: | KATELYN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776879 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 411 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025880850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2014 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 55729 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01079254A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0006X | 01079254A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080P0006X | 56397 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080P0006X | 55729 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100660090 | 05 | KY | MEDICAID |