Provider Demographics
NPI:1861501728
Name:WARD, KATHLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:WARD
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 1:1400 W 47TH ST
Mailing Address - Street 2:SUITE1
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6141
Mailing Address - Country:US
Mailing Address - Phone:708-698-4563
Mailing Address - Fax:708-361-7968
Practice Address - Street 1:1400 W 47TH ST
Practice Address - Street 2:SUITE1
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6141
Practice Address - Country:US
Practice Address - Phone:708-698-4563
Practice Address - Fax:708-361-7968
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071078207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071078Medicaid
E19252Medicare UPIN
IL036071078Medicaid