Provider Demographics
NPI:1558374652
Name:BLAHA, GEORGIA (RD)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:
Last Name:BLAHA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8148 CLARENDON HILLS RD
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-2689
Mailing Address - Country:US
Mailing Address - Phone:708-951-6736
Mailing Address - Fax:630-654-8527
Practice Address - Street 1:1525 W HOMER ST
Practice Address - Street 2:STE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1280
Practice Address - Country:US
Practice Address - Phone:773-292-1940
Practice Address - Fax:773-292-1939
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK01138Medicare ID - Type UnspecifiedREGISTERED DIETITIAN