Provider Demographics
NPI:1679574735
Name:GRIEM, KATHERINE LESLIE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:LESLIE
Last Name:GRIEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-0074
Mailing Address - Country:US
Mailing Address - Phone:630-734-9560
Mailing Address - Fax:630-734-9565
Practice Address - Street 1:6801 W 34TH ST
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-5591
Practice Address - Country:US
Practice Address - Phone:705-484-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360672922085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067292Medicaid
ILP04852Medicare PIN
C39405Medicare UPIN