Healthcare Provider Details

I. General information

NPI: 1235593476
Provider Name (Legal Business Name): EMMA ANSELIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE # 152
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

2116 W CULLOM AVE UNIT 201
CHICAGO IL
60618-1754
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-7410
  • Fax:
Mailing address:
  • Phone: 217-979-7435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036148678
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: