=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558687038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA E.S. XENIDIS D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2010
-----------------------------------------------------
Last Update Date | 11/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5801 S CASS AVE
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-971-2645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5801 S CASS AVE
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559-2397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-971-2645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 036.135191
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------