Provider Demographics
NPI:1790245371
Name:LEVINE, MAX MONAHAN
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:MONAHAN
Last Name:LEVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:STE 240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5745
Mailing Address - Country:US
Mailing Address - Phone:708-236-2673
Mailing Address - Fax:
Practice Address - Street 1:1611 W HARRISON ST STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:708-236-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002736A363A00000X
IL085.006969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant