Provider Demographics
NPI:1720066418
Name:SZPUR, MARY V (PAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:SZPUR
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 W POLK ST
Mailing Address - Street 2:STE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3723
Mailing Address - Country:US
Mailing Address - Phone:312-864-0451
Mailing Address - Fax:312-864-9686
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-685-1000
Practice Address - Fax:847-685-6685
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001173363AM0700X, 363AS0400X
IL085-001173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL501100Medicare PIN
ILP45472Medicare UPIN
ILK21615Medicare PIN
IL212417Medicare PIN
ILK21614Medicare PIN