=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538620661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ALEJANDRA MEJIA BAUTISTA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2019
-----------------------------------------------------
Last Update Date | 12/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 251 E HURON ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-926-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RESIDENCIAL QUINTAS CALIFORNIA BLOCK C,#2,CARRETERA A ACAJUTLA
-----------------------------------------------------
City | SONSONATE
-----------------------------------------------------
State | SONSONATE
-----------------------------------------------------
Zip | 00000
-----------------------------------------------------
Country | SV
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 125.073979
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 036.159362
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------