Basic Information
Provider Information
NPI: 1740244151
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DILLEY
FirstName: KIMBERLEY
MiddleName: JO
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4440 W 95TH ST
Address2:  
City: OAK LAWN
State: IL
PostalCode: 604532600
CountryCode: US
TelephoneNumber: 7086848000
FaxNumber:  
Practice Location
Address1: 4440 W 95TH ST
Address2:  
City: OAK LAWN
State: IL
PostalCode: 604532600
CountryCode: US
TelephoneNumber: 7086848000
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/13/2006
LastUpdateDate: 02/26/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X036106926ILY Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
03610692605IL MEDICAID


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