1588643670 NPI number — MARIA PICKEN MD PHD

Table of content: MARIA PICKEN MD PHD (NPI 1588643670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588643670 NPI number — MARIA PICKEN MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKEN
Provider First Name:
MARIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1588643670
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 S FIRST AVE
Provider Second Line Business Mailing Address:
(EMS BLDG., RM. 2209)
Provider Business Mailing Address City Name:
MAYWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-216-3250
Provider Business Mailing Address Fax Number:
708-216-2620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2160 S FIRST AVE
Provider Second Line Business Practice Location Address:
(EMS BLDG., RM. 2209)
Provider Business Practice Location Address City Name:
MAYWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-216-3250
Provider Business Practice Location Address Fax Number:
708-216-2620
Provider Enumeration Date:
01/17/2006

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: 207ZP0101X , with the licence number:  36077578 , 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: 36077578 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".