Provider Demographics
NPI:1871635078
Name:MIANOWSKA, ANNA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:
Last Name:MIANOWSKA
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:MIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:6039 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-5150
Mailing Address - Country:US
Mailing Address - Phone:847-266-9550
Mailing Address - Fax:847-266-9144
Practice Address - Street 1:6039 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-5116
Practice Address - Country:US
Practice Address - Phone:773-622-6095
Practice Address - Fax:773-622-8706
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057827208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001623407OtherBLUE CROSS - BLUE SHIELD
IL036057827Medicaid
ILD15949Medicare UPIN
IL036057827Medicaid