Basic Information
| Provider Information | |||||||||
| NPI: | 1710425228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BICKEL | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | GIFFORD | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GIFFORD | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | MICKELLE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 240 E HURON ST | ||||||||
| Address2: | NORTHWESTERN MCGAW MEDICAL CENTER SUITE 1-200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125037975 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 240 E HURON ST | ||||||||
| Address2: | NORTHWESTERN MCGAW MEDICAL CENTER SUITE 1-200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125037975 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.