Healthcare Provider Details

I. General information

NPI: 1861493165
Provider Name (Legal Business Name): KATHERINE FACKLIS KOUVELIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE FACKLIS

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date: 03/22/2006
Reactivation Date: 04/11/2006

III. Provider practice location address

1221 N HIGHLAND AVE
AURORA IL
60506-1404
US

IV. Provider business mailing address

2357 SEQUOIA DR
AURORA IL
60506-6222
US

V. Phone/Fax

Practice location:
  • Phone: 630-859-8700
  • Fax:
Mailing address:
  • Phone: 630-859-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036118061
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036118061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: