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General NPI Number Information
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NPI Number | 1033838081
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Entity Type | Organization
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Legal Business Name | IMMAKULATE PSYCHIATRY LLC
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Dates
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Enumeration Date | 08/23/2022
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Last Update Date | 08/23/2022
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Provider Practice Location Address
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Address Line | 5730 W ROOSEVELT RD
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City | CHICAGO
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State | IL
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Zip | 60644-1580
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Country | US
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Telephone | 773-413-1700
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Fax |
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Provider Business Mailing Address
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Address Line | 1373 DIVISION ST
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-3059
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Country | US
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Telephone | 847-280-1505
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Fax |
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Authorized Official
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Title or Position | PROVIDER
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Name | AHMED MAKI
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Credential | DO
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Telephone | 847-280-1505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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