Healthcare Provider Details

I. General information

NPI: 1326543232
Provider Name (Legal Business Name): ELIZABETH KUDLATY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2018
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

251 E HURON ST
CHICAGO IL
60611-3055
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-2088
  • Fax: 312-996-3896
Mailing address:
  • Phone: 312-926-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number036155325
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036155325
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: