Provider Demographics
NPI:1861493165
Name:KOUVELIS, KATHERINE FACKLIS (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:FACKLIS
Last Name:KOUVELIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:FACKLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2357 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-6222
Mailing Address - Country:US
Mailing Address - Phone:630-859-6800
Mailing Address - Fax:
Practice Address - Street 1:1221 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1404
Practice Address - Country:US
Practice Address - Phone:630-859-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-11-18
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
IL036118061208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0451514334OtherBLUESHIELD PROVIDER#
H16738Medicare UPIN
ILK45756Medicare PIN
IL0727500001Medicare NSC
ILK45757Medicare PIN