=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316142383
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE MARIE MISCH M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1747 W ROOSEVELT RD M-C 747
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-1264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-996-6219
-----------------------------------------------------
Fax | 312-996-9534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 431 GREENLEAF AVE
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-920-1820
-----------------------------------------------------
Fax | 847-920-1821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------