Healthcare Provider Details

I. General information

NPI: 1336500263
Provider Name (Legal Business Name): ALYSSA RAE COHEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2016
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

714 W BUCKINGHAM PL APT 2E
CHICAGO IL
60657-6502
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 216-346-9506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.068458
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.148492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: