MEDICARE: KAITLYN MARIE MIDDAUGH MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	208000000X	Pediatrics Physician	58927	KY

General Provider Information

NPI Number	:	1659937407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN MARIE MIDDAUGH MD

Provider Business Mailing Address
First Line	:	PO BOX 776879
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-6879
Country	:	US
Telephone Number	:	502-559-9425
Fax Number	:

Provider Business Practice Location Address
First Line	:	12955 SHELBYVILLE RD STE 1
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40243-1538
Country	:	US
Telephone Number	:	502-254-2223
Fax Number	:

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

Provider Enumeration Date	:	05/17/2019
Last Update Date	:	08/02/2024

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