Provider Demographics
NPI:1245345545
Name:ANDRICACOU, CALLIOPE C (MD)
Entity type:Individual
Prefix:
First Name:CALLIOPE
Middle Name:C
Last Name:ANDRICACOU
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 1:2850 W 95TH ST
Mailing Address - Street 2:#404
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805
Mailing Address - Country:US
Mailing Address - Phone:708-423-4000
Mailing Address - Fax:708-423-4097
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:#404
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:708-423-4000
Practice Address - Fax:708-423-4097
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058640208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21608967OtherBCBS
01152Medicare UPIN