Healthcare Provider Details

I. General information

NPI: 1538489869
Provider Name (Legal Business Name): KRISTIN W HOUSEKNECHT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 W MONROE ST
CHICAGO IL
60661-3654
US

IV. Provider business mailing address

1074 W TAYLOR ST UNIT 319
CHICAGO IL
60607-4336
US

V. Phone/Fax

Practice location:
  • Phone: 312-258-0700
  • Fax:
Mailing address:
  • Phone: 813-495-2785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME108909
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01077086A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN14997
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number036.142542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: