Healthcare Provider Details

I. General information

NPI: 1912081597
Provider Name (Legal Business Name): TAMARA MARSHALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 S LONGWOOD DR
CHICAGO IL
60643-2057
US

IV. Provider business mailing address

10150 S LONGWOOD DR
CHICAGO IL
60643-2057
US

V. Phone/Fax

Practice location:
  • Phone: 773-350-1101
  • Fax:
Mailing address:
  • Phone: 773-350-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-096367
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: