1588757579 NPI number — KATHERINE ANNE WIDERBORG MD

Table of content: KATHERINE ANNE WIDERBORG MD (NPI 1588757579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588757579 NPI number — KATHERINE ANNE WIDERBORG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIDERBORG
Provider First Name:
KATHERINE
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1588757579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 EASTLAND DR
Provider Second Line Business Mailing Address:
SUITE 2300
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61701-3534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-662-9022
Provider Business Mailing Address Fax Number:
309-662-2091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1537 FORT JESSE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-808-0122
Provider Business Practice Location Address Fax Number:
309-808-0552
Provider Enumeration Date:
10/02/2006

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: 208600000X , with the licence number:  036-068927 , 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: 0360689271 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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