Healthcare Provider Details

I. General information

NPI: 1013446731
Provider Name (Legal Business Name): KATHERINE S MCCROSSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST FL 13
CHICAGO IL
60611-3926
US

IV. Provider business mailing address

259 E ERIE ST FL 13
CHICAGO IL
60611-3926
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6800
  • Fax: 312-926-6600
Mailing address:
  • Phone: 312-695-6800
  • Fax: 312-926-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007764
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: