Healthcare Provider Details

I. General information

NPI: 1962518613
Provider Name (Legal Business Name): CHRISTINE MELITTA ANDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE DEPT. OF RADIOLOGY
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

1330 KENILWORTH LN
GLENVIEW IL
60025-2204
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7820
  • Fax:
Mailing address:
  • Phone: 847-363-7353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-071577
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: