Healthcare Provider Details

I. General information

NPI: 1174458350
Provider Name (Legal Business Name): MARY THERESE FORSYTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 N CALIFORNIA AVE
CHICAGO IL
60625-3645
US

IV. Provider business mailing address

1900 N SHEFFIELD AVE APT 3S
CHICAGO IL
60614-8449
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax:
Mailing address:
  • Phone: 847-525-9171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125088529
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: