Provider Demographics
NPI:1285612259
Name:WEBER, KATHLEEN M (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:WEBER
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 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:#240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 W. HARRISON
Practice Address - Street 2:SUITE 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-431-3400
Practice Address - Fax:312-942-1517
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099936207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7785085OtherAETNA ID#
IL036099936 2Medicaid
IL207067OtherMEDICARE PTIN LOCALITY 16
IL207073OtherMEDICARE PTAN LOCALITY 15
ILDA4902OtherRR MEDICARE PTAN #
ILP00091153OtherRR MEDICARE ID#
IL1633878OtherBCBS GROUP #
ILH05642Medicare UPIN
ILDA4902OtherRR MEDICARE PTAN #
IL036099936 2Medicaid