Healthcare Provider Details

I. General information

NPI: 1770613689
Provider Name (Legal Business Name): IRENE PANAYOTOU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4564 N BROADWAY ST
CHICAGO IL
60640-5602
US

IV. Provider business mailing address

1300 N LAKE SHORE DR APT 37D
CHICAGO IL
60610-5163
US

V. Phone/Fax

Practice location:
  • Phone: 773-271-9700
  • Fax:
Mailing address:
  • Phone: 312-664-7399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-037853
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: