Healthcare Provider Details

I. General information

NPI: 1245345545
Provider Name (Legal Business Name): CALLIOPE C ANDRICACOU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 W 95TH ST #404
EVERGREEN PARK IL
60805
US

IV. Provider business mailing address

2850 W 95TH ST #404
EVERGREEN PARK IL
60805
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-4000
  • Fax: 708-423-4097
Mailing address:
  • Phone: 708-423-4000
  • Fax: 708-423-4097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036058640
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier21608967
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: