Healthcare Provider Details

I. General information

NPI: 1669741997
Provider Name (Legal Business Name): KATELYN M RUGINO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATELYN M BEACH PA-C

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N WALL ST STE 530
KANKAKEE IL
60901-3483
US

IV. Provider business mailing address

375 N WALL ST STE 530
KANKAKEE IL
60901-3483
US

V. Phone/Fax

Practice location:
  • Phone: 815-932-7200
  • Fax: 815-935-8797
Mailing address:
  • Phone: 815-932-7200
  • Fax: 815-935-8797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004856RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: