Healthcare Provider Details

I. General information

NPI: 1063832996
Provider Name (Legal Business Name): CHRISTINA BOUTSICARIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CENTRAL ST STE 800
EVANSTON IL
60201-1780
US

IV. Provider business mailing address

1000 CENTRAL ST STE 800
EVANSTON IL
60201-1780
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-1122
  • Fax: 847-570-1123
Mailing address:
  • Phone: 847-570-2503
  • Fax: 847-570-3060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number036.143907
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: