Provider Demographics
NPI:1831135615
Name:THACHENKERY, MARIA C (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:C
Last Name:THACHENKERY
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 1:1673 ASHBURY DR
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-8407
Mailing Address - Country:US
Mailing Address - Phone:630-243-1686
Mailing Address - Fax:630-243-1687
Practice Address - Street 1:2619 E 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3705
Practice Address - Country:US
Practice Address - Phone:773-375-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE13613Medicare UPIN