=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104049782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFECIRCLE WOMENS HEALTH SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7800 W COLLEGE DRIVE
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-361-2400
-----------------------------------------------------
Fax | 708-361-1592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7800 W COLLEGE DRIVE
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-361-2400
-----------------------------------------------------
Fax | 708-361-2400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KIMBERLY ANNE MULLIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-301-6751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------