Provider Demographics
NPI:1588757579
Name:WIDERBORG, KATHERINE ANNE (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:WIDERBORG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3534
Mailing Address - Country:US
Mailing Address - Phone:309-662-9022
Mailing Address - Fax:309-662-2091
Practice Address - Street 1:1537 FORT JESSE RD
Practice Address - Street 2:SUITE A
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761
Practice Address - Country:US
Practice Address - Phone:309-808-0122
Practice Address - Fax:309-808-0552
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-068927208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360689271Medicaid
IL777460Medicare ID - Type Unspecified
IL0360689271Medicaid