1386724243 NPI number — MS. JUDITH MIZRACHI L.C.P.C.

Table of content: MS. JUDITH MIZRACHI L.C.P.C. (NPI 1386724243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386724243 NPI number — MS. JUDITH MIZRACHI L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIZRACHI
Provider First Name:
JUDITH
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.P.C.
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:
1386724243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1347 W GREENLEAF AVE
Provider Second Line Business Mailing Address:
UNIT 2
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60626-2916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-575-4307
Provider Business Mailing Address Fax Number:
773-764-2038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5419 N SHERIDAN RD
Provider Second Line Business Practice Location Address:
SUITE 103 A
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640-1964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-575-4307
Provider Business Practice Location Address Fax Number:
773-764-2038
Provider Enumeration Date:
10/16/2006

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: 101YP2500X , with the licence number:  180-005474 , 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: 1634661 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: U0348-0591 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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