Basic Information
| Provider Information | |||||||||
| NPI: | 1548250186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E DAY RD | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465453455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742379340 | ||||||||
| FaxNumber: | 5742391474 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E DAY RD | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465453455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742379340 | ||||||||
| FaxNumber: | 5742391474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 11/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 01055115A | IN | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0000X | 01055115A | IN | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200349420 | 05 | IN | MEDICAID |