Healthcare Provider Details

I. General information

NPI: 1245267780
Provider Name (Legal Business Name): M. KATHLEEN K BUETOW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W UNIVERSITY AVE
URBANA IL
61801-2530
US

IV. Provider business mailing address

P.O. BOX 6002
URBANA IL
61803-6002
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3311
  • Fax:
Mailing address:
  • Phone: 217-326-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036040299
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: