Provider Demographics
NPI:1801983283
Name:MCMAHAN-CLEMIS INSTITUTE OF OTOLARYNGOLOGY SC
Entity type:Organization
Organization Name:MCMAHAN-CLEMIS INSTITUTE OF OTOLARYNGOLOGY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NYLANI
Authorized Official - Middle Name:S
Authorized Official - Last Name:ALICEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-266-6673
Mailing Address - Street 1:151 N MICHIGAN AVE
Mailing Address - Street 2:STE 913
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7506
Mailing Address - Country:US
Mailing Address - Phone:312-266-6673
Mailing Address - Fax:312-266-3680
Practice Address - Street 1:151 N MICHIGAN AVE
Practice Address - Street 2:STE 913
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7538
Practice Address - Country:US
Practice Address - Phone:312-266-6673
Practice Address - Fax:312-266-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214532OtherMEDICARE PTAN