Provider Demographics
NPI:1700817244
Name:MIKHAILOV, MARY J (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:MIKHAILOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:J
Other - Last Name:HAUTSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-260-0600
Mailing Address - Fax:630-260-1370
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-260-0600
Practice Address - Fax:630-260-1370
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078879208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363149833OtherTAX IDENTIFICATION NUMBER
IL0222075OtherBLUE CROSS GROUP NUMBER
IL548190001OtherMEDICARE INDIVIDUAL PTAN
IL3631498336019001OtherCDPG HFS PAYEE ID
IL036078879Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER
IL363149833OtherTAX IDENTIFICATION NUMBER