Provider Demographics
NPI:1407092323
Name:MERLITA C. CRUZAT-BLANCO, M.D. , L.L.C.
Entity Type:Organization
Organization Name:MERLITA C. CRUZAT-BLANCO, M.D. , L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MERLITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CRUZAT-BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-975-9957
Mailing Address - Street 1:2800 N SHERIDAN RD
Mailing Address - Street 2:SUITE 205N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6156
Mailing Address - Country:US
Mailing Address - Phone:773-975-9957
Mailing Address - Fax:773-975-3930
Practice Address - Street 1:2800 N SHERIDAN RD STE 205N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6161
Practice Address - Country:US
Practice Address - Phone:773-975-9957
Practice Address - Fax:773-975-3930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1413Medicare PIN