Provider Demographics
NPI:1790726651
Name:EYTAN, ALYSE (MD)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:EYTAN
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 1:201 E HURON ST
Mailing Address - Street 2:9-235
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-926-3540
Mailing Address - Fax:312-926-3538
Practice Address - Street 1:201 E HURON ST
Practice Address - Street 2:9-235
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3197
Practice Address - Country:US
Practice Address - Phone:312-926-3540
Practice Address - Fax:312-926-3538
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
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
ILN/AMedicaid
ILN/AMedicare ID - Type Unspecified
ILN/AMedicaid