Healthcare Provider Details

I. General information

NPI: 1508056227
Provider Name (Legal Business Name): KATHLEEN M MONDEREWICZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 6TH AVE
HUNTINGTON WV
25701-2104
US

IV. Provider business mailing address

119 BELLEFONTE DR
ASHLAND KY
41101-2109
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-4202
  • Fax: 304-525-4231
Mailing address:
  • Phone: 606-325-6967
  • Fax: 304-525-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36297
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21708
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: