Healthcare Provider Details

I. General information

NPI: 1265826853
Provider Name (Legal Business Name): KATARZYNA MONIKA MIKRUT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 DEMPSTER ST STE 555
PARK RIDGE IL
60068-1188
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-698-5500
  • Fax: 847-698-5517
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-143989
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036-143989
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: