MEDICARE: ELIE KHADR MANGOUBI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician		IL

General Provider Information

NPI Number	:	1396794194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIE KHADR MANGOUBI MD

Provider Business Mailing Address
First Line	:	1000 N LAKE SHORE PLZ
Second Line	:	26C
City	:	CHICAGO
State	:	IL
Zip	:	60611-1354
Country	:	US
Telephone Number	:	312-787-7865
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 N WABASH AVE
Second Line	:	3805
City	:	CHICAGO
State	:	IL
Zip	:	60611-3591
Country	:	US
Telephone Number	:	312-787-7865
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	11/01/2007

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