Provider Demographics
NPI:1982836680
Name:ANGELLA CHARNOT-KATSIKAS, LTD
Entity Type:Organization
Organization Name:ANGELLA CHARNOT-KATSIKAS, LTD
Other - Org Name:MEDITERRANEAN MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARNOT-KATSIKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-691-4472
Mailing Address - Street 1:11555 S HARLEM AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-2300
Mailing Address - Country:US
Mailing Address - Phone:708-691-4472
Mailing Address - Fax:708-671-1433
Practice Address - Street 1:11555 S HARLEM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-2300
Practice Address - Country:US
Practice Address - Phone:708-691-4472
Practice Address - Fax:708-671-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121904261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center