Healthcare Provider Details

I. General information

NPI: 1730744152
Provider Name (Legal Business Name): COURTNEY NICOLE SEVERIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3773
US

IV. Provider business mailing address

162 W ELIZABETH DR
SCHERERVILLE IN
46375-2176
US

V. Phone/Fax

Practice location:
  • Phone: 219-775-2613
  • Fax:
Mailing address:
  • Phone: 219-775-2613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberA201706
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA201706
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: