Provider Demographics
NPI:1932465259
Name:DETWILER, KATHLEEN ELIZABETH (PHD, MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:DETWILER
Suffix:
Gender:F
Credentials:PHD, MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:MANDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:248 E QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2178
Mailing Address - Country:US
Mailing Address - Phone:630-202-4852
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:LUH NORTH ENTRANCE, NUCLEAR MEDICINE
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-202-7000
Practice Address - Fax:708-216-6890
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250614722085N0904X
ILXXXXXXXXXXXXXXXX207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology