Healthcare Provider Details

I. General information

NPI: 1588733067
Provider Name (Legal Business Name): MAIRGHREAD R WYCKLENDT RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR SAINT JOSEPH HOSPITAL
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

2900 N LAKE SHORE DR SAINT JOSEPH HOSPITAL
CHICAGO IL
60657-5640
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-3069
  • Fax: 773-665-6231
Mailing address:
  • Phone: 773-665-3069
  • Fax: 773-665-6231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: