1356367429 NPI number — DR. JUDITH LYNN MARCIN MD

Table of content: DR. JUDITH LYNN MARCIN MD (NPI 1356367429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356367429 NPI number — DR. JUDITH LYNN MARCIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARCIN
Provider First Name:
JUDITH
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIGHT
Provider Other First Name:
JUDITH
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356367429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2013
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:
STE 406
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:
312-633-5841
Provider Business Mailing Address Fax Number:
312-491-5020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1431 N WESTERN AVE
Provider Second Line Business Practice Location Address:
STE 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:
07/14/2006

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:  036108355 , 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: 036108355 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".