1801999339 NPI number — MRS. TAMARA PHILANA MARTIN-SANFORD MACCCSLPL

Table of content: MRS. TAMARA PHILANA MARTIN-SANFORD MACCCSLPL (NPI 1801999339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801999339 NPI number — MRS. TAMARA PHILANA MARTIN-SANFORD MACCCSLPL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN-SANFORD
Provider First Name:
TAMARA
Provider Middle Name:
PHILANA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MACCCSLPL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
TAMARA
Provider Other Middle Name:
PHILANA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MACCCSLPL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801999339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4734 S CHAMPLAIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60615-1504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-373-0442
Provider Business Mailing Address Fax Number:
773-373-0442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5820 W IRVING PARK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-685-8482
Provider Business Practice Location Address Fax Number:
773-685-8479
Provider Enumeration Date:
09/07/2006

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: 235Z00000X , with the licence number:  146005363 , 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)





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