Provider Demographics
NPI:1104200310
Name:MEGELLIE, MENA (MD)
Entity Type:Individual
Prefix:
First Name:MENA
Middle Name:
Last Name:MEGELLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 E 50TH ST
Mailing Address - Street 2:APT 19K
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3127
Mailing Address - Country:US
Mailing Address - Phone:708-830-3745
Mailing Address - Fax:
Practice Address - Street 1:1500 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608
Practice Address - Country:US
Practice Address - Phone:773-542-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.067887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine