Provider Demographics
NPI:1477058378
Name:MIRA, RANIM
Entity Type:Individual
Prefix:
First Name:RANIM
Middle Name:
Last Name:MIRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 W BELLE PLAINE AVE # GE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2412
Mailing Address - Country:US
Mailing Address - Phone:773-619-3810
Mailing Address - Fax:
Practice Address - Street 1:4021 W BELLE PLAINE AVE # GE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2412
Practice Address - Country:US
Practice Address - Phone:312-730-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-24
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL08323081207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine