Healthcare Provider Details

I. General information

NPI: 1619606696
Provider Name (Legal Business Name): MICHELLAI KIERRA PARKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S MICHIGAN AVE
CHICAGO IL
60605-2810
US

IV. Provider business mailing address

8455 S PHILLIPS AVE
CHICAGO IL
60617-1971
US

V. Phone/Fax

Practice location:
  • Phone: 312-454-2700
  • Fax:
Mailing address:
  • Phone: 773-726-7274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.175760
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: