Healthcare Provider Details

I. General information

NPI: 1578882015
Provider Name (Legal Business Name): IRINI N KOLAITIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

225 E CHCIAGO AVE BOX #152
CHICAGO IL
60611-2605
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036132725
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: