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NPI Code Detail

MEDICARE: KATHERINE BLOODWORTH MNP

MEDICARE: KATHERINE BLOODWORTH MNP
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
1363L00000XNurse Practitioner209005931IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2P00635208OTHERILRR MEDICARE ID

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1CG2264OTHERILRR MED GRP ID

General Provider Information

NPI Number : 1154415008
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHERINE BLOODWORTH MNP
Provider Business Mailing Address
First Line : 1501 MCPHERSON AVE
Second Line :
City : MOUNT VERNON
State : IL
Zip : 62864-2831
Country : US
Telephone Number : 618-241-1748
Fax Number :
Provider Business Practice Location Address
First Line : 1501 MCPHERSON AVE
Second Line :
City : MOUNT VERNON
State : IL
Zip : 62864-2831
Country : US
Telephone Number : 618-241-1748
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/03/2006
Last Update Date : 11/26/2008

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Directions to “ KATHERINE BLOODWORTH MNP” Practice Location

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