Provider Demographics
NPI:1649512195
Name:KETTERER, ANDREW R (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:R
Last Name:KETTERER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:87 WYMAN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1904
Mailing Address - Country:US
Mailing Address - Phone:319-594-2307
Mailing Address - Fax:
Practice Address - Street 1:211 E ONTARIO ST STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3284
Practice Address - Country:US
Practice Address - Phone:312-926-7000
Practice Address - Fax:312-926-6274
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA270150207P00000X
IL036170215207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine