Healthcare Provider Details

I. General information

NPI: 1639445331
Provider Name (Legal Business Name): SOREL LIRA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 W 19TH ST
CHICAGO IL
60623-3501
US

IV. Provider business mailing address

4318 S FORRESTVILLE AVE
CHICAGO IL
60653-4176
US

V. Phone/Fax

Practice location:
  • Phone: 773-484-1000
  • Fax:
Mailing address:
  • Phone: 773-543-3979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036137621
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036137621
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: