Healthcare Provider Details

I. General information

NPI: 1649780818
Provider Name (Legal Business Name): MEGAN M HAYNES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE STE M331M274
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

600 W DIVERSEY PKWY APT 1305
CHICAGO IL
60614-1563
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax: 773-293-4171
Mailing address:
  • Phone: 859-221-8352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006296
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number085006296
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: