Provider Demographics
NPI:1831109172
Name:ROSALES, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROSALES
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 1:3450 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6837
Mailing Address - Country:US
Mailing Address - Phone:773-523-1000
Mailing Address - Fax:773-843-1553
Practice Address - Street 1:3450 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6837
Practice Address - Country:US
Practice Address - Phone:773-523-1000
Practice Address - Fax:773-843-1553
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-075789208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE95008Medicare UPIN
367830Medicare PIN