Provider Demographics
NPI:1336159839
Name:MASSA, MARY C (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:MASSA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 264
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-2195
Mailing Address - Fax:312-563-2263
Practice Address - Street 1:6319 FAIRVIEW AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-2888
Practice Address - Country:US
Practice Address - Phone:630-968-4500
Practice Address - Fax:630-968-4420
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL68912Medicare PIN
D15166Medicare UPIN