Healthcare Provider Details

I. General information

NPI: 1396906749
Provider Name (Legal Business Name): KATHERINE A DIEMER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 KIWANIS DR
FREEPORT IL
61032-6907
US

IV. Provider business mailing address

515 22ND AVE
MONROE WI
53566-1569
US

V. Phone/Fax

Practice location:
  • Phone: 815-235-1406
  • Fax:
Mailing address:
  • Phone: 608-324-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57640
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125051266
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: