Healthcare Provider Details

I. General information

NPI: 1578266896
Provider Name (Legal Business Name): GELIQUE AYALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S PAULINA ST STE 403
CHICAGO IL
60612-3806
US

IV. Provider business mailing address

5000 W CHAMBERS ST
MILWAUKEE WI
53210-1650
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-4270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125.084006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: