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NPI Code Detail

MEDICARE: ALYSSA BRIE KETCHUM PA-C

MEDICARE: ALYSSA BRIE KETCHUM PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AS0400XSurgical Physician Assistant085005549IL

General Provider Information

NPI Number : 1104200625
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALYSSA BRIE KETCHUM PA-C
Provider Business Mailing Address
First Line : 676 N SAINT CLAIR ST STE 1900
Second Line :
City : CHICAGO
State : IL
Zip : 60611-2986
Country : US
Telephone Number : 312-926-5354
Fax Number :
Provider Business Practice Location Address
First Line : 676 N SAINT CLAIR ST STE 1900
Second Line :
City : CHICAGO
State : IL
Zip : 60611-2986
Country : US
Telephone Number : 312-926-5354
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/14/2015
Last Update Date : 12/17/2018

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Directions to “ ALYSSA BRIE KETCHUM PA-C” Practice Location

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