Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RH0003X | Hematology & Oncology | 36111532 | IL |
NPI | 1013994086 |
---|---|
Provider Name | Shelly Lo |
First Address | Maywood, IL 60153-3328 |
Second Address | Maywood, IL 60153-3328 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2005 |
Last Update Date | 01/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
36111532 | (05) | IL |