1225263247 NPI number — DR. SARAH KATHERINE COSTIANIS DC

Table of content: DR. SARAH KATHERINE COSTIANIS DC (NPI 1225263247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225263247 NPI number — DR. SARAH KATHERINE COSTIANIS DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTIANIS
Provider First Name:
SARAH
Provider Middle Name:
KATHERINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEMLEY
Provider Other First Name:
SARAH
Provider Other Middle Name:
KATIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1225263247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 N MARION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60302-1813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-407-1080
Provider Business Mailing Address Fax Number:
800-360-7697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
167 N MARION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60301-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-407-1080
Provider Business Practice Location Address Fax Number:
800-360-7697
Provider Enumeration Date:
05/19/2009

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: 111N00000X , with the licence number:  38011422 , 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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