MEDICARE: KATHLEEN A GOLOS RD

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
1	133V00000X	Registered Dietitian	769	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	769-029	OTHER		CERTIFIED DIETITIAN

General Provider Information

NPI Number	:	1376874156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN A GOLOS RD

Provider Business Mailing Address
First Line	:	5709 ANCHORAGE AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-4401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5709 ANCHORAGE AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53705-4401
Country	:	US
Telephone Number	:	608-233-8264
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2010
Last Update Date	:	12/01/2021

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Directions to “ KATHLEEN A GOLOS RD” Practice Location

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