Provider Demographics
NPI:1760471031
Name:EVRARD, MARILYN L (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:L
Last Name:EVRARD
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 1:1200 S YORK ST
Mailing Address - Street 2:STE. 3280
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5626
Mailing Address - Country:US
Mailing Address - Phone:630-758-8640
Mailing Address - Fax:630-758-8642
Practice Address - Street 1:1200 S YORK RD
Practice Address - Street 2:STE 3280
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5626
Practice Address - Country:US
Practice Address - Phone:630-758-8640
Practice Address - Fax:630-758-8642
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036023688207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036023688Medicaid
IL036023688Medicaid
IL900003072Medicare PIN
ILL76441Medicare PIN
ILT01506Medicare PIN
IL632010Medicare PIN
ILL76442Medicare PIN