Healthcare Provider Details

I. General information

NPI: 1841280922
Provider Name (Legal Business Name): THERESA J LIE-NEMETH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S. CALIFORNIA BLVD.
CHICAGO IL
60608
US

IV. Provider business mailing address

1401 S. CALIFORNIA BLVD.
CHICAGO IL
60608
US

V. Phone/Fax

Practice location:
  • Phone: 773-522-5857
  • Fax: 773-522-5886
Mailing address:
  • Phone: 773-522-5857
  • Fax: 773-522-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number220616
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036109913
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: