=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508869744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STASIA E RICHTER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2005
-----------------------------------------------------
Last Update Date | 09/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1725 W HARRISON ST STE 318
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-942-6647
-----------------------------------------------------
Fax | 312-942-3730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12632 S HARLEM AVE
-----------------------------------------------------
City | PALOS HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60463-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-587-0000
-----------------------------------------------------
Fax | 708-623-7628
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 036075143
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------