Provider Demographics
NPI:1649578279
Name:MCCLINTOCK, KATHERINE M (PA)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:M
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3745
Mailing Address - Country:US
Mailing Address - Phone:773-631-7898
Mailing Address - Fax:773-631-3005
Practice Address - Street 1:7447 W TALCOTT AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3745
Practice Address - Country:US
Practice Address - Phone:773-631-7898
Practice Address - Fax:773-631-3005
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23014665363A00000X
FLPA9106434363A00000X
IL085-004668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGB240ZMedicare PIN