Basic Information
| Provider Information | |||||||||
| NPI: | 1932465259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETWILER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MANDELL | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 248 E QUINCY ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605462178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302024852 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | LUH NORTH ENTRANCE, NUCLEAR MEDICINE | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082027000 | ||||||||
| FaxNumber: | 7082166890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2012 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | 125061472 | IL | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 207R00000X | XXXXXXXXXXXXXXXX | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.