Healthcare Provider Details

I. General information

NPI: 1619504842
Provider Name (Legal Business Name): MARCELLINE KEBU KEMMY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S WOLCOTT AVE
CHICAGO IL
60612-3748
US

IV. Provider business mailing address

820 S WOOD ST STE 100
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-9858
  • Fax:
Mailing address:
  • Phone: 312-996-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number125.084763
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0000000027
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: