1336460807 NPI number — DR. STEPHANIE ELIZABETH PLACE M.D.

Table of content: DR. STEPHANIE ELIZABETH PLACE M.D. (NPI 1336460807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336460807 NPI number — DR. STEPHANIE ELIZABETH PLACE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PLACE
Provider First Name:
STEPHANIE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336460807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1431 N WESTERN AVE
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60622-1797
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1431 N WESTERN AVE
Provider Second Line Business Practice Location Address:
SUITE 406
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-1797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-633-5841
Provider Business Practice Location Address Fax Number:
312-491-5020
Provider Enumeration Date:
06/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  036131979 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036131979 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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