Healthcare Provider Details

I. General information

NPI: 1932465259
Provider Name (Legal Business Name): KATHLEEN ELIZABETH DETWILER PHD, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN ELIZABETH MANDELL

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE LUH NORTH ENTRANCE, NUCLEAR MEDICINE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

248 E QUINCY ST
RIVERSIDE IL
60546-2178
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-7000
  • Fax: 708-216-6890
Mailing address:
  • Phone: 630-202-4852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number125061472
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberXXXXXXXXXXXXXXXX
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: