Provider Demographics
NPI:1568807618
Name:SIEBENALER, MARY KATHERINE SCOTT (MD, FAAP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE SCOTT
Last Name:SIEBENALER
Suffix:
Gender:F
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE # 152
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-7408
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE # 152
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-227-7408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119823208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014994200Medicaid
FLIE506ZMedicare PIN