Healthcare Provider Details

I. General information

NPI: 1205001187
Provider Name (Legal Business Name): LUCY MUNOZ MEDINA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST ROOM 440, CLINICAL SCIENCES NORTH
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

1901 W HARRISON ST ROOM 440, CLINICAL SCIENCES NORTH
CHICAGO IL
60612-3714
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7700
  • Fax: 312-413-8283
Mailing address:
  • Phone: 312-864-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-119916
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number336081139
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number336081139
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: