Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 036054765 | IL |
N | 2080N0001X | Neonatal-Perinatal Doctor | 036054765 | IL |
NPI | 1134201205 |
---|---|
Provider Name | Mary Abby Adams |
First Address | Evanston, IL 60201-1718 |
Second Address | Evanston, IL 60201-1718 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2006 |
Last Update Date | 02/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036054765 | (05) | IL |
1620385 | BLUE SHIELD (01) | IL |
T38516 | (02) | IL |