Basic Information
| Provider Information | |||||||||
| NPI: | 1801154000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNON-LOEW | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | E | ||||||||
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| OtherLastName: | GANNON | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7974 UW HEALTH CT | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535625531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295485 | ||||||||
| FaxNumber: | 6082636547 | ||||||||
| Practice Location | |||||||||
| Address1: | 2880 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537053644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082636421 | ||||||||
| FaxNumber: | 6082636547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 07/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 35.126176 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 61745-20 | WI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0133627 | 05 | OH | MEDICAID |