Healthcare Provider Details

I. General information

NPI: 1740201060
Provider Name (Legal Business Name): MARTA BANEGAS, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 N LA SALLE DR
CHICAGO IL
60610-3204
US

IV. Provider business mailing address

PO BOX 388320
CHICAGO IL
60638-8320
US

V. Phone/Fax

Practice location:
  • Phone: 773-767-8283
  • Fax:
Mailing address:
  • Phone: 776-767-4600
  • Fax: 773-767-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MARTA BANEGAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-767-8283