Healthcare Provider Details

I. General information

NPI: 1154645604
Provider Name (Legal Business Name): MAURA DICKINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

IV. Provider business mailing address

26460 NETWORK PL
CHICAGO IL
60673-1264
US

V. Phone/Fax

Practice location:
  • Phone: 773-542-2000
  • Fax:
Mailing address:
  • Phone: 773-257-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036135376
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02005313A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: