Healthcare Provider Details

I. General information

NPI: 1871138933
Provider Name (Legal Business Name): BRIGID M. MARIETTA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-1900
  • Fax:
Mailing address:
  • Phone: 312-227-6190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number209019879
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: