Provider Demographics
NPI:1336104348
Name:KLEIN-GITELMAN, MARISA SUE (MD MPH)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:SUE
Last Name:KLEIN-GITELMAN
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:#50
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-880-4360
Mailing Address - Fax:773-880-4179
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:#50
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-880-4360
Practice Address - Fax:773-880-4179
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360893172080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036039317Medicaid
IL036039317Medicaid
ILK14894Medicare ID - Type Unspecified