Basic Information
| Provider Information | |||||||||
| NPI: | 1861430225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEHLER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GALL | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 27127 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489097127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313466800 | ||||||||
| FaxNumber: | 2313466017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1105 SIXTH ST | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496842349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319355000 | ||||||||
| FaxNumber: | 2313466017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036103015 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 036103015 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036103015 | 05 | IL | MEDICAID | 05-0540914 | 01 | IL | WELLGROUP TAX ID | OTHER |