Healthcare Provider Details

I. General information

NPI: 1962640250
Provider Name (Legal Business Name): SONYA PAISLEY AGNEW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST DEPT OF PLASTIC AND RECONSTRUCTIVE SURGERY, SUITE19-250
CHICAGO IL
60611-5975
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6022
  • Fax:
Mailing address:
  • Phone: 708-216-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036.122286
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: