Provider Demographics
NPI:1841810389
Name:MCKIMMON, MARY (RDMS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCKIMMON
Suffix:
Gender:F
Credentials:RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 W BERTEAU AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2940
Mailing Address - Country:US
Mailing Address - Phone:312-401-7706
Mailing Address - Fax:
Practice Address - Street 1:2250 W BERTEAU AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-2940
Practice Address - Country:US
Practice Address - Phone:312-401-7706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2402432085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound