Provider Demographics
NPI:1942566641
Name:PICKARD, MAURICE (MAURICE PICKARD)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:PICKARD
Suffix:
Gender:M
Credentials:MAURICE PICKARD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 PAINTERS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2121
Mailing Address - Country:US
Mailing Address - Phone:847-579-0779
Mailing Address - Fax:
Practice Address - Street 1:2115 PAINTERS LAKE RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2121
Practice Address - Country:US
Practice Address - Phone:847-579-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.038028207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine