Healthcare Provider Details

I. General information

NPI: 1063605889
Provider Name (Legal Business Name): CHANNA MAAYAN-FRANK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 HANANIA STREET
JERUSALEM IL
93106
IL

IV. Provider business mailing address

7 HANANIA STREET
JERUSALEM IL
93106
IL

V. Phone/Fax

Practice location:
  • Phone: 297-258-4451
  • Fax:
Mailing address:
  • Phone: 297-258-4451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number59817
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: