=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720474885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHWISE MEDICAL CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2015
-----------------------------------------------------
Last Update Date | 04/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8349 S BALTIMORE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-978-5291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8349 S BALTIMORE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-978-5291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARIE MYRLANDE KERNIZAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 773-978-5291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 036.099858
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------