Basic Information
| Provider Information | |||||||||
| NPI: | 1053606103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONLIFFE | ||||||||
| FirstName: | KATHRINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRANTZ | ||||||||
| OtherFirstName: | KATHRINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776879 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 4010 DUPONT CIR STE 283 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028971727 | ||||||||
| FaxNumber: | 5028950827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2011 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 03688 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7100317450 | 05 | KY | MEDICAID |