Healthcare Provider Details

I. General information

NPI: 1780116590
Provider Name (Legal Business Name): DINAH KATE HAMILTON THIBEAULT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-6602
  • Fax:
Mailing address:
  • Phone: 773-702-6602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number287837
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.152927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: