Healthcare Provider Details

I. General information

NPI: 1326192428
Provider Name (Legal Business Name): MARY ELLEN PAVONE MD, MSCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST STE 2400
CHICAGO IL
60611-3907
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 2310
CHICAGO IL
60611-2915
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-7269
  • Fax: 312-695-4924
Mailing address:
  • Phone: 312-695-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberP18023
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number036118744
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: