Healthcare Provider Details

I. General information

NPI: 1487189973
Provider Name (Legal Business Name): ASSIA MEZIANE-TANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2017
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST FL 19
CHICAGO IL
60611-2987
US

IV. Provider business mailing address

259 E ERIE ST FL 19
CHICAGO IL
60611-2987
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-7950
  • Fax:
Mailing address:
  • Phone: 312-695-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number57.029578
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036.156407
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: