Provider Demographics
NPI:1093855835
Name:NELSON, SENORA (MD)
Entity Type:Individual
Prefix:
First Name:SENORA
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 288080
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-8080
Mailing Address - Country:US
Mailing Address - Phone:773-233-4100
Mailing Address - Fax:773-233-4055
Practice Address - Street 1:901 E SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1166
Practice Address - Country:US
Practice Address - Phone:773-233-4100
Practice Address - Fax:773-233-4055
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106244208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106244Medicaid
K49976Medicare PIN