Provider Demographics
NPI:1790951093
Name:WESTERHOLM, MARY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MICHAEL
Last Name:WESTERHOLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1222
Mailing Address - Country:US
Mailing Address - Phone:630-653-0848
Mailing Address - Fax:630-653-7746
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1222
Practice Address - Country:US
Practice Address - Phone:630-653-0848
Practice Address - Fax:630-653-7746
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116854207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0222075OtherBLUE CROSS GROUP NUMBER
IL036116854Medicaid
IL3631498336019001OtherCDPG HFS PAYEE ID
IL363149833OtherTAX IDENTIFICATION NUMBER
IL487450OtherMEDICARE GROUP NUMBER
ILP00659358OtherMEDICARE RAILROAD
ILP00659358OtherMEDICARE RAILROAD