Healthcare Provider Details

I. General information

NPI: 1033135686
Provider Name (Legal Business Name): MARIJANA LJUBANOVIC LAZAREVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY 735 JELKE ANESTHESIA DEPARTMENT
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY 735 JELKE ANESTHESIA DEPARTMENT
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6504
  • Fax: 312-942-5773
Mailing address:
  • Phone: 312-942-6504
  • Fax: 312-942-5773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036-093273
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: