Kathleen C Antolak, M.D.
Individual provider Active NPI Family Medicine Physician · Bend, OR
NPI 1316975741 · NPPES record last updated Jan 29, 2021
Key facts
- NPI
- 1316975741
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- MD23421 (OR)
- Practice address
- 1501 NE Medical Center Dr
Bend, OR 97701-6051 - Phone
- (541) 382-2811
- NPI assigned
- Jun 28, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in OR
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20061227000355 | OR | Practitioner - Family Practice | 2365346095 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MD23421 | OR | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Bend Memorial Clinic PC | Current |
Accepting new patients | |
| Bend Memorial Clinic PC | Family Medicine | Current |
Accepting new patients |
Locations
1501 NE Medical Center Dr
Bend, OR 97701
Phone (541) 317-4354
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | MD23421 | OR | Yes |
| Specialist | 174400000X | MD23421 | OR |
Addresses
Primary practice location
1501 NE Medical Center Dr
Bend, OR 97701-6051
Mailing address
1501 NE Medical Center Dr
Bend, OR 97701-6051
Phone (541) 382-2811
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 287220 | Medicaid | OR | |
| 00479094 | Other | OR | RAILROAD |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | kantolak4558@directmsg.bmctotalcare.com |
Other providers in Bend, OR
- Alisa Anguiano
- Nathan Ansbaugh
- Aubrey Anselmo
- Randee Jean Anshutz
- Tracey Anthony
- Apex Spine and Performance
- Steven David Apfelbaum
- Dawna L Applehans
- Aqua Terra Health
- Manuel Montano Aragon
All providers in Bend, OR · Family Medicine Physician in Oregon
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 29, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.