Healthcare Provider Details

I. General information

NPI: 1821258724
Provider Name (Legal Business Name): MYESHA JANELL BANKS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5159 S ASHLAND AVE
CHICAGO IL
60609-4931
US

IV. Provider business mailing address

5159 S ASHLAND AVE
CHICAGO IL
60609-4931
US

V. Phone/Fax

Practice location:
  • Phone: 773-434-9216
  • Fax: 773-434-2670
Mailing address:
  • Phone: 773-434-9216
  • Fax: 773-434-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125050971
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: