MEDICARE: KATHLEEN H MALOUL MD PC

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	207Q00000X	Family Medicine Physician	036078007	IL

General Provider Information

NPI Number	:	1407099310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATHLEEN H MALOUL MD PC

Provider Business Mailing Address
First Line	:	3414 W PETERSON AVE
Second Line	:	SUITE D
City	:	CHICAGO
State	:	IL
Zip	:	60659-3452
Country	:	US
Telephone Number	:	773-267-0422
Fax Number	:

Provider Business Practice Location Address
First Line	:	3414 W PETERSON AVE
Second Line	:	SUITE D
City	:	CHICAGO
State	:	IL
Zip	:	60659-3452
Country	:	US
Telephone Number	:	773-267-0422
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KATHLEEN MALOUL
Credential	:	M.D.
Telephone Number	:	773-267-0422

Provider Enumeration Date	:	04/08/2009
Last Update Date	:	04/08/2009

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