Provider Demographics
NPI:1649218397
Name:MOE, KATHLEEN H (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:H
Last Name:MOE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:H
Other - Last Name:MALOUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2740 W FOSTER AVE
Mailing Address - Street 2:STE LL7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3543
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:3414 W PETERSON AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3452
Practice Address - Country:US
Practice Address - Phone:773-267-0422
Practice Address - Fax:773-267-0561
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078007174400000X, 207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078007Medicaid
IL036078007Medicaid
IL951212001Medicare PIN