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General NPI Number Information
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NPI Number | 1548247794
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Entity Type | Individual
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Provider Name | EUSTATHIA J. PANOUSHIS M.D.
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Gender | Female
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Dates
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Enumeration Date | 12/29/2005
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Last Update Date | 11/30/2007
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Provider Practice Location Address
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Address Line | 201 E HURON ST GALTER AMBULATORY PAVILLION SUITE 12-260
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City | CHICAGO
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State | IL
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Zip | 60611-3197
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Country | US
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Telephone | 312-926-9570
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Fax | 312-926-6776
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Provider Business Mailing Address
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Address Line | 1350 W FULLERTON AVE #405
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City | CHICAGO
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State | IL
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Zip | 60614-2198
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Country | US
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Telephone | 773-327-2156
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State | IL
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