Healthcare Provider Details

I. General information

NPI: 1265056659
Provider Name (Legal Business Name): ELIZABETH NICOLE MANCUSO MB BCH BAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date: 01/18/2022
Reactivation Date: 02/02/2022

III. Provider practice location address

5841 S MARYLAND AVE # MC1145
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-3020
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number036.165352
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: