Provider Demographics
NPI:1801154000
Name:GANNON-LOEW, KATHRYN E
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
Last Name:GANNON-LOEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:608-829-5485
Mailing Address - Fax:608-263-6547
Practice Address - Street 1:2880 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3644
Practice Address - Country:US
Practice Address - Phone:608-263-6421
Practice Address - Fax:608-263-6547
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1261762080A0000X
WI61745-202080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0133627Medicaid