MEDICARE: DR. MIA ELISE LAYNE M.D.

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	207V00000X	Obstetrics & Gynecology Physician	036140767	IL

General Provider Information

NPI Number	:	1417210931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MIA ELISE LAYNE M.D.

Provider Business Mailing Address
First Line	:	2007 S STATE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2173
Country	:	US
Telephone Number	:	773-340-2546
Fax Number	:	773-340-2547

Provider Business Practice Location Address
First Line	:	2007 S STATE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2173
Country	:	US
Telephone Number	:	773-340-2546
Fax Number	:	773-340-2547

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

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	08/19/2025

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