Provider Demographics
NPI:1689247850
Name:KAM MEDICAL LLC
Entity Type:Organization
Organization Name:KAM MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-339-3111
Mailing Address - Street 1:PO BOX 7306
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-7306
Mailing Address - Country:US
Mailing Address - Phone:352-339-3111
Mailing Address - Fax:
Practice Address - Street 1:1320 S PLYMOUTH CT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2717
Practice Address - Country:US
Practice Address - Phone:352-339-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109814Medicaid
ILF100783497OtherMEDICARE