Healthcare Provider Details

I. General information

NPI: 1003900556
Provider Name (Legal Business Name): ERIN MICHELLE TABACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 CHICAGO AVE
OAK PARK IL
60302-1803
US

IV. Provider business mailing address

1107 CHICAGO AVE
OAK PARK IL
60302-1803
US

V. Phone/Fax

Practice location:
  • Phone: 708-383-2900
  • Fax: 708-383-2969
Mailing address:
  • Phone: 708-383-2900
  • Fax: 708-383-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-098343
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: