Provider Demographics
NPI:1134277395
Name:TAYLOR, TINA M (DN)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:M
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8733 S WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5451
Mailing Address - Country:US
Mailing Address - Phone:773-298-1220
Mailing Address - Fax:
Practice Address - Street 1:400 W 76TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-1640
Practice Address - Country:US
Practice Address - Phone:773-873-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL181000230172P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172P00000XOther Service ProvidersNaprapath
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001625785OtherBCBS PROVIDER #