Provider Demographics
NPI:1730373259
Name:MOLINE, KATHLEEN CARROLL (DO)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:CARROLL
Last Name:MOLINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1800 N MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-260-0600
Mailing Address - Fax:630-260-1370
Practice Address - Street 1:1800 N MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-260-0600
Practice Address - Fax:630-260-1370
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049243207Q00000X
IL036119323207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00646859OtherMEDICARE RAILROAD PTAN (INDIVIDUAL)
ILR03102OtherMEDICARE PTAN (INDIVIDUAL)
IL548190OtherMEDICARE PTAN (GROUP)
ILCA4748OtherMEDICARE RAILROAD PTAN (GROUP)