Healthcare Provider Details

I. General information

NPI: 1225491954
Provider Name (Legal Business Name): MAI TUE NGUYEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4753 N BROADWAY ST SUITE 910
CHICAGO IL
60640-4991
US

IV. Provider business mailing address

4753 N BROADWAY ST SUITE 910
CHICAGO IL
60640-4991
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-2780
  • Fax: 773-989-2781
Mailing address:
  • Phone: 773-989-2780
  • Fax: 773-989-2781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.149677
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: