Provider Demographics
NPI:1841385259
Name:KA-WIDMANN, HYSOO (MD)
Entity Type:Individual
Prefix:
First Name:HYSOO
Middle Name:
Last Name:KA-WIDMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HYSOO
Other - Middle Name:
Other - Last Name:KA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423
Mailing Address - Country:US
Mailing Address - Phone:815-463-3000
Mailing Address - Fax:815-463-3013
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9524
Practice Address - Country:US
Practice Address - Phone:815-463-3000
Practice Address - Fax:815-463-3013
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105467207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105467OtherBCBS
IL0361054671Medicaid
ILG97526Medicare UPIN
ILK10776Medicare UPIN
ILP00266522Medicare ID - Type UnspecifiedRR MEDICARE