Healthcare Provider Details

I. General information

NPI: 1093276016
Provider Name (Legal Business Name): IDIA AREBANMHEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IDIA IFIANAYI MD

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

319 DOVER DR
DES PLAINES IL
60018-1133
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 224-735-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036162337
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: