Provider Demographics
NPI:1528190907
Name:FAYEN, MAUREEN (MD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:FAYEN
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 1:405 N WABASH AVE
Mailing Address - Street 2:SUITE 1815
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3591
Mailing Address - Country:US
Mailing Address - Phone:312-222-0015
Mailing Address - Fax:312-527-0849
Practice Address - Street 1:405 N WABASH AVE
Practice Address - Street 2:SUITE 1815
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3591
Practice Address - Country:US
Practice Address - Phone:312-222-0015
Practice Address - Fax:312-527-0849
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL741250Medicare ID - Type Unspecified
ILD15781Medicare UPIN