Healthcare Provider Details

I. General information

NPI: 1336400217
Provider Name (Legal Business Name): ELIZABETH ANNE KIRACOFE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 W FULTON ST
CHICAGO IL
60661-1144
US

IV. Provider business mailing address

618 W FULTON ST
CHICAGO IL
60661-1144
US

V. Phone/Fax

Practice location:
  • Phone: 847-766-0829
  • Fax: 847-892-4992
Mailing address:
  • Phone: 847-766-0829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.021857
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036-141403
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: