Healthcare Provider Details

I. General information

NPI: 1801154000
Provider Name (Legal Business Name): KATHRYN E GANNON-LOEW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHRYN GANNON

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 07/03/2022
Certification Date: 07/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 UNIVERSITY AVE
MADISON WI
53705-3644
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-6421
  • Fax: 608-263-6547
Mailing address:
  • Phone: 608-829-5485
  • Fax: 608-263-6547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number35.126176
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number61745-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: