Provider Demographics
NPI:1114949211
Name:KANASHIRO, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:KANASHIRO
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 1:27702 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1277
Mailing Address - Country:US
Mailing Address - Phone:708-862-7674
Mailing Address - Fax:708-862-1781
Practice Address - Street 1:6703 W 159TH STREET
Practice Address - Street 2:SUITE 109
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1782
Practice Address - Country:US
Practice Address - Phone:708-532-1104
Practice Address - Fax:708-532-5539
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088831Medicaid
IL231199013OtherMEDICARE
ILP00940434OtherRRM
ILG14003Medicare UPIN
ILK19155Medicare PIN
ILK50321Medicare PIN