1356367429 NPI number — DR. JUDITH LYNN MARCIN MD

Table of content: (NPI 1326249137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356367429 NPI number — DR. JUDITH LYNN MARCIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARCIN
Provider First Name:
JUDITH
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIGHT
Provider Other First Name:
JUDITH
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356367429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1431 N WESTERN AVE
Provider Second Line Business Mailing Address:
STE 406
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60622-1797
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-633-5841
Provider Business Mailing Address Fax Number:
312-491-5020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1431 N WESTERN AVE
Provider Second Line Business Practice Location Address:
STE 406
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-1797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-633-5841
Provider Business Practice Location Address Fax Number:
312-491-5020
Provider Enumeration Date:
07/14/2006

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: 207Q00000X , with the licence number:  036108355 , 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: 036108355 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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