1982836680 NPI number — ANGELLA CHARNOT-KATSIKAS, LTD

Table of content: (NPI 1982836680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982836680 NPI number — ANGELLA CHARNOT-KATSIKAS, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGELLA CHARNOT-KATSIKAS, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDITERRANEAN MEDICINE
Provider Other Organization Name Type Code:
3
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:
1982836680
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11555 S HARLEM AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
WORTH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60482-2300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-691-4472
Provider Business Mailing Address Fax Number:
708-671-1433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11555 S HARLEM AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
WORTH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60482-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-691-4472
Provider Business Practice Location Address Fax Number:
708-671-1433
Provider Enumeration Date:
08/13/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHARNOT-KATSIKAS
Authorized Official First Name:
ANGELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / MEDICAL DIRECTOR
Authorized Official Telephone Number:
708-691-4472

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  036121904 , 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)