Provider Demographics
NPI:1629021787
Name:LADIEN, KIMBALL H (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBALL
Middle Name:H
Last Name:LADIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4325
Mailing Address - Country:US
Mailing Address - Phone:773-883-0200
Mailing Address - Fax:773-883-0090
Practice Address - Street 1:1011 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4325
Practice Address - Country:US
Practice Address - Phone:773-883-0200
Practice Address - Fax:773-883-0090
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE40244Medicare UPIN
IL396570Medicare ID - Type UnspecifiedMEDICARE