Healthcare Provider Details

I. General information

NPI: 1922126390
Provider Name (Legal Business Name): MARIAM MATHEW KAPPIL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

225 E CHICAGO AVE # 9
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5503
  • Fax:
Mailing address:
  • Phone: 312-227-3501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301087412
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number036-125488
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036125488
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-125488
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: