Provider Demographics
NPI:1811785819
Name:GEORGE, THERESA PERICLES
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:PERICLES
Last Name:GEORGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1949 N HUDSON AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1949 N HUDSON AVE APT 1F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5250
Practice Address - Country:US
Practice Address - Phone:314-277-9140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program