Provider Demographics
NPI:1912492448
Name:IMIG, MARY KATHERINE (DO)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:IMIG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MAXINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550
Mailing Address - Country:US
Mailing Address - Phone:309-263-2411
Mailing Address - Fax:309-263-2208
Practice Address - Street 1:411 MAXINE DRIVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550
Practice Address - Country:US
Practice Address - Phone:309-263-2411
Practice Address - Fax:309-263-2208
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036154510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine