Provider Demographics
NPI:1023088903
Name:FOURNIER, KATHLEEN K (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:K
Last Name:FOURNIER
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:PO BOX 24007
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-9007
Mailing Address - Country:US
Mailing Address - Phone:618-222-9999
Mailing Address - Fax:618-222-9337
Practice Address - Street 1:4600 MEMORIAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5366
Practice Address - Country:US
Practice Address - Phone:618-222-9999
Practice Address - Fax:618-222-9337
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL546390Medicare ID - Type Unspecified
ILH81454Medicare UPIN