1386337483 NPI number — MISS KATHERINE CLARK KETCHUM M.D.

Table of content: MISS KATHERINE CLARK KETCHUM M.D. (NPI 1386337483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386337483 NPI number — MISS KATHERINE CLARK KETCHUM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETCHUM
Provider First Name:
KATHERINE
Provider Middle Name:
CLARK
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386337483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 PELHAM PARKWAY SOUTH, JACOBI MEDICAL CENTER
Provider Second Line Business Mailing Address:
BUILDING 4 ROOM 6S11
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-918-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 PELHAM PKWY SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-918-4084
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2023

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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