Provider Demographics
NPI:1750489050
Name:KATTAH, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:KATTAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-624-4000
Mailing Address - Fax:309-624-4010
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-624-4000
Practice Address - Fax:309-624-4010
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0968822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096882Medicaid
IL036096882Medicaid
IL201951Medicare ID - Type UnspecifiedGROUP #
IL846910Medicare ID - Type UnspecifiedGROUP #
ILL62851Medicare ID - Type UnspecifiedINDIVIDUAL #
ILL64261Medicare ID - Type UnspecifiedINDIVIDUAL #
C88776Medicare UPIN
ILL91919Medicare ID - Type UnspecifiedINDIVIDUAL
IL130018181 - CA4079Medicare ID - Type UnspecifiedRR