1306172754 NPI number — MS. KATE W. FONTANA

Table of content: MS. KATE W. FONTANA (NPI 1306172754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306172754 NPI number — MS. KATE W. FONTANA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTANA
Provider First Name:
KATE
Provider Middle Name:
W.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEGLER
Provider Other First Name:
KATE
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306172754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 S FRONTAGE RD
Provider Second Line Business Mailing Address:
SUITE 325
Provider Business Mailing Address City Name:
WOODRIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60517-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-981-3680
Provider Business Mailing Address Fax Number:
847-956-5122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 BIESTERFIELD RD STE G01
Provider Second Line Business Practice Location Address:
WIMMER BUILDING
Provider Business Practice Location Address City Name:
ELK GROVE VILLAGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60007-3372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-981-3680
Provider Business Practice Location Address Fax Number:
847-956-5122
Provider Enumeration Date:
10/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  085003615 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IL6305021 . This is a "MEDICARE PIN-LOC 15" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P01058191 . This is a "RRMC PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IL6304021 . This is a "MEDICARE PIN-LOC 16" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1720371669 . This is a "NPI GROUP PRACTICE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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