Healthcare Provider Details

I. General information

NPI: 1679669691
Provider Name (Legal Business Name): BLAINE HANNAFIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST ADVOCATE CHRIST MEDICAL CENTER: EMERGENCY DEPT.
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

4440 W 95TH ST ADVOCATE CHRIST MEDICAL CENTER: EMERGENCY DEPT.
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-4077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35799
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.122086
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: