Healthcare Provider Details

I. General information

NPI: 1801809322
Provider Name (Legal Business Name): MARY THERESE UCKERMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W NORTH AVE
MELROSE PARK IL
60160-1612
US

IV. Provider business mailing address

701 W NORTH AVE
MELROSE PARK IL
60160-1612
US

V. Phone/Fax

Practice location:
  • Phone: 708-681-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036087252
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number036087252
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: