Healthcare Provider Details

I. General information

NPI: 1689247850
Provider Name (Legal Business Name): KAM MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 S PLYMOUTH CT
CHICAGO IL
60605-2717
US

IV. Provider business mailing address

PO BOX 7306
CAROL STREAM IL
60197-7306
US

V. Phone/Fax

Practice location:
  • Phone: 352-339-3111
  • Fax:
Mailing address:
  • Phone: 352-339-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KATRINA MATTINGLY
Title or Position: OWNER
Credential: MD
Phone: 352-339-3111