Provider Demographics
NPI:1255317533
Name:YANEZ, MARTHA (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:YANEZ
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 1:2525 S MICHIGAN AVE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2477
Mailing Address - Country:US
Mailing Address - Phone:312-567-5677
Mailing Address - Fax:312-567-6189
Practice Address - Street 1:5525 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4400
Practice Address - Country:US
Practice Address - Phone:312-567-7500
Practice Address - Fax:312-447-7740
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088167208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBS OF IL
IL428610Medicare ID - Type UnspecifiedGROUP 950150
ILG 68918Medicare UPIN