Healthcare Provider Details

I. General information

NPI: 1215217286
Provider Name (Legal Business Name): ISMENE POTAKIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 14-200
CHICAGO IL
60611-5966
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 14-200
CHICAGO IL
60611-5966
US

V. Phone/Fax

Practice location:
  • Phone: 126-957-5423
  • Fax: 312-695-5462
Mailing address:
  • Phone: 312-695-7542
  • Fax: 126-955-4623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004104
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: