Basic Information
| Provider Information | |||||||||
| NPI: | 1689133936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLISCH | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3724 E MAFFEO RD | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850508341 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 251 E HURON ST | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129262000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2019 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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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 | 208600000X | 125.074327 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.