Provider Demographics
NPI:1225013998
Name:JOHN, ANNIE (MD)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:JOHN
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:P.O. BOX 2248
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60132-0001
Mailing Address - Country:US
Mailing Address - Phone:847-676-0091
Mailing Address - Fax:773-248-2348
Practice Address - Street 1:3434 W PETERSON AVE
Practice Address - Street 2:1A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3319
Practice Address - Country:US
Practice Address - Phone:773-583-5803
Practice Address - Fax:773-248-2348
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068169207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068169Medicaid
IL036068169Medicaid