Healthcare Provider Details

I. General information

NPI: 1649578279
Provider Name (Legal Business Name): KATHERINE M. MCCLINTOCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE SUITE 500
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

7447 W TALCOTT AVE SUITE 500
CHICAGO IL
60631-3745
US

V. Phone/Fax

Practice location:
  • Phone: 773-631-7898
  • Fax: 773-631-3005
Mailing address:
  • Phone: 773-631-7898
  • Fax: 773-631-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23014665
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106434
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-004668
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: