Provider Demographics
NPI:1417210931
Name:LAYNE, MIA ELISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:ELISE
Last Name:LAYNE
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 1:2007 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2173
Mailing Address - Country:US
Mailing Address - Phone:773-340-2546
Mailing Address - Fax:773-340-2547
Practice Address - Street 1:2007 S STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2173
Practice Address - Country:US
Practice Address - Phone:773-340-2546
Practice Address - Fax:773-340-2547
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036140767207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology