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4646 N Marine Dr Chicago IL 60640-5759 | |
| (773) 878-8700 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | General Practice |
| Location | 4646 N Marine Dr, Chicago, Illinois |
| Authorized Official Name and Position | Manoj R Prasad (CEO) |
| Authorized Official Contact | 7087636700 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4646 N Marine Dr Chicago IL 60640-5759 Ph: (773) 878-8700 | 4646 N Marine Dr Chicago IL 60640-5759 Ph: (773) 878-8700 |
| NPI Number | 1205301926 |
|---|---|
| Provider Enumeration Date | 10/09/2018 |
| Last Update Date | 12/22/2022 |
| Medicare PECOS PAC ID | 5991046468 |
|---|---|
| Medicare Enrollment ID | O20190410000827 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1205301926 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | (* (Not Available)) | Primary |
| Provider Name | Nichole Butler Mooyoung |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1245222108 PECOS PAC ID: 1557275096 Enrollment ID: I20031118000608 |
| Provider Name | Georgeann L Iacono Russell |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1164552154 PECOS PAC ID: 3779478854 Enrollment ID: I20040218000111 |
| Provider Name | Olumuyiwa Idowu |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1538254511 PECOS PAC ID: 3476445594 Enrollment ID: I20040325000595 |
| Provider Name | Daniel G Torres |
|---|---|
| Provider Type | Practitioner - Rheumatology |
| Provider Identifiers | NPI Number: 1629002860 PECOS PAC ID: 5496745580 Enrollment ID: I20040512000905 |
| Provider Name | Melanie Jessen |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1972531507 PECOS PAC ID: 1850283490 Enrollment ID: I20040517000760 |
| Provider Name | Max L Harris |
|---|---|
| Provider Type | Practitioner - Rheumatology |
| Provider Identifiers | NPI Number: 1053349886 PECOS PAC ID: 1951385350 Enrollment ID: I20040615000104 |
| Provider Name | Paul R Abbo |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1083693378 PECOS PAC ID: 2567437205 Enrollment ID: I20040827000016 |
| Provider Name | Alam Ali Khan |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1316946288 PECOS PAC ID: 9931174026 Enrollment ID: I20040901000297 |
| Provider Name | David R Schatz |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1962497925 PECOS PAC ID: 2062480197 Enrollment ID: I20040921000159 |
| Provider Name | Allan Tachauer |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1679506489 PECOS PAC ID: 7214906544 Enrollment ID: I20041001000980 |
| Provider Name | Isoken Koko |
|---|---|
| Provider Type | Practitioner - Hematology/oncology |
| Provider Identifiers | NPI Number: 1265465728 PECOS PAC ID: 4587627252 Enrollment ID: I20041104000725 |
| Provider Name | Sabah A Khan |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1992778534 PECOS PAC ID: 9335102524 Enrollment ID: I20041109000437 |
| Provider Name | Clement S Rose |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1346238177 PECOS PAC ID: 4981667185 Enrollment ID: I20041109000501 |
| Provider Name | Timothy J Oconnell |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1194766618 PECOS PAC ID: 4880642305 Enrollment ID: I20050111000410 |
| Provider Name | Tayeb S Hussain |
|---|---|
| Provider Type | Practitioner - Podiatry |
| Provider Identifiers | NPI Number: 1487688925 PECOS PAC ID: 2163412321 Enrollment ID: I20050222000827 |
| Provider Name | Kevin L Keele |
|---|---|
| Provider Type | Practitioner - Interventional Radiology |
| Provider Identifiers | NPI Number: 1992768402 PECOS PAC ID: 7618907585 Enrollment ID: I20050819000662 |
| Provider Name | Carolyn Elaine Fitzpatrick |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1205872462 PECOS PAC ID: 9739107467 Enrollment ID: I20051110000507 |
| Provider Name | Lawrence S Zachary |
|---|---|
| Provider Type | Practitioner - Plastic And Reconstructive Surgery |
| Provider Identifiers | NPI Number: 1477646222 PECOS PAC ID: 5698785251 Enrollment ID: I20060426000569 |
| Provider Name | Ozuru O Ukoha |
|---|---|
| Provider Type | Practitioner - Thoracic Surgery |
| Provider Identifiers | NPI Number: 1942247457 PECOS PAC ID: 0244236040 Enrollment ID: I20061019000144 |
| Provider Name | Barry D Lessin |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1457372054 PECOS PAC ID: 7416948468 Enrollment ID: I20070404000283 |
| Provider Name | Fabio Sbrana |
|---|---|
| Provider Type | Practitioner - General Surgery |
| Provider Identifiers | NPI Number: 1205037520 PECOS PAC ID: 8628177730 Enrollment ID: I20070629000336 |
| Provider Name | Thomas A Mcnally |
|---|---|
| Provider Type | Practitioner - Orthopedic Surgery |
| Provider Identifiers | NPI Number: 1306857727 PECOS PAC ID: 7113015694 Enrollment ID: I20071116000231 |
| Provider Name | Peter E Eupierre |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1528069481 PECOS PAC ID: 2466526041 Enrollment ID: I20080730000566 |
| Provider Name | Sherif A Milik |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1427251792 PECOS PAC ID: 6002979192 Enrollment ID: I20090115000625 |
| Provider Name | John Joseph Walsh |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1740384338 PECOS PAC ID: 4981754629 Enrollment ID: I20090618000165 |
| Provider Name | Steven A Sandler |
|---|---|
| Provider Type | Practitioner - Hematology/oncology |
| Provider Identifiers | NPI Number: 1326129792 PECOS PAC ID: 6901945328 Enrollment ID: I20091124000664 |
| Provider Name | Thomas Bielanski |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1326089160 PECOS PAC ID: 3375686678 Enrollment ID: I20100209000571 |
| Provider Name | Scott Levin |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1295779775 PECOS PAC ID: 0648275669 Enrollment ID: I20100323000703 |
| Provider Name | Frederick A Barber |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1659475242 PECOS PAC ID: 1254481997 Enrollment ID: I20110126000092 |
| Provider Name | Kyung Yoo |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1992946511 PECOS PAC ID: 6507919479 Enrollment ID: I20110811000223 |
| Provider Name | Rajdeep K Dhami |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1558657791 PECOS PAC ID: 2062650971 Enrollment ID: I20140711001371 |
| Provider Name | Samindi Malika Gunasekara |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1407155096 PECOS PAC ID: 1850510405 Enrollment ID: I20140915001341 |
| Provider Name | Samuel Guirguis |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1831332832 PECOS PAC ID: 8628390952 Enrollment ID: I20141124000228 |
| Provider Name | Saud Ahmed |
|---|---|
| Provider Type | Practitioner - Interventional Radiology |
| Provider Identifiers | NPI Number: 1255592655 PECOS PAC ID: 0840416756 Enrollment ID: I20150106002488 |
| Provider Name | Vladimir Urbin |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1740570696 PECOS PAC ID: 4981918687 Enrollment ID: I20150807013944 |
| Provider Name | Evan S Greenbaum |
|---|---|
| Provider Type | Practitioner - Otolaryngology |
| Provider Identifiers | NPI Number: 1750511564 PECOS PAC ID: 2961629605 Enrollment ID: I20151103001984 |
| Provider Name | Jeanette Kelly |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1154769081 PECOS PAC ID: 7810120714 Enrollment ID: I20160713002781 |
| Provider Name | Haritha Dukkipati |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1811289424 PECOS PAC ID: 3678867041 Enrollment ID: I20170711001801 |
| Provider Name | Sujatha Kailas |
|---|---|
| Provider Type | Practitioner - Gastroenterology |
| Provider Identifiers | NPI Number: 1861473936 PECOS PAC ID: 0749207223 Enrollment ID: I20171201000486 |
| Provider Name | Ramin Ghazizadeh |
|---|---|
| Provider Type | Practitioner - Podiatry |
| Provider Identifiers | NPI Number: 1649652140 PECOS PAC ID: 2567771363 Enrollment ID: I20180503000021 |
| Provider Name | Ayham Alagha |
|---|---|
| Provider Type | Practitioner - Hospitalist |
| Provider Identifiers | NPI Number: 1851779151 PECOS PAC ID: 0749598209 Enrollment ID: I20180619002540 |
| Provider Name | Daniel P Ignell |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1780244244 PECOS PAC ID: 9931436565 Enrollment ID: I20190806000300 |
| Provider Name | Shiraz Rahim |
|---|---|
| Provider Type | Practitioner - Interventional Radiology |
| Provider Identifiers | NPI Number: 1073856118 PECOS PAC ID: 0749535607 Enrollment ID: I20190930002270 |
| Provider Name | Victoria Shih Lee |
|---|---|
| Provider Type | Practitioner - Otolaryngology |
| Provider Identifiers | NPI Number: 1174899066 PECOS PAC ID: 4587981402 Enrollment ID: I20191024000686 |
| Provider Name | Supriya Gupta |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1548521883 PECOS PAC ID: 5092004523 Enrollment ID: I20200113001847 |
| Provider Name | Emad N Yacoub |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1982803532 PECOS PAC ID: 7911099437 Enrollment ID: I20200625001381 |
| Provider Name | Lindsey Kurdi Wood |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1902336266 PECOS PAC ID: 9638449952 Enrollment ID: I20200918000570 |
| Provider Name | Sebastian Ko |
|---|---|
| Provider Type | Practitioner - Orthopedic Surgery |
| Provider Identifiers | NPI Number: 1902367642 PECOS PAC ID: 0244568707 Enrollment ID: I20201005000988 |
| Provider Name | Rachel Heather Prokopf |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1083276703 PECOS PAC ID: 8325468549 Enrollment ID: I20201008002980 |
| Provider Name | Maja Boshkovska Spaseski |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1205366812 PECOS PAC ID: 9234548496 Enrollment ID: I20210512000990 |
| Provider Name | Rashad Hammour |
|---|---|
| Provider Type | Practitioner - Hospitalist |
| Provider Identifiers | NPI Number: 1396234571 PECOS PAC ID: 2466851175 Enrollment ID: I20210601000884 |
| Provider Name | Shamit Desai |
|---|---|
| Provider Type | Practitioner - Interventional Radiology |
| Provider Identifiers | NPI Number: 1285074104 PECOS PAC ID: 2961747555 Enrollment ID: I20210715004030 |
| Provider Name | Matthew Joseph Rudolph |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1942791702 PECOS PAC ID: 3274936539 Enrollment ID: I20210723000990 |
| Provider Name | Monica R. Thipparthi |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1700370988 PECOS PAC ID: 9032465174 Enrollment ID: I20210731000321 |
| Provider Name | Judith Disterhoft |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1093154809 PECOS PAC ID: 4486932647 Enrollment ID: I20220405000484 |
| Provider Name | Efrain Aguilar Murillo |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1467865444 PECOS PAC ID: 6103119250 Enrollment ID: I20220412001813 |
| Provider Name | Ammar Taha |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1992032577 PECOS PAC ID: 1850538968 Enrollment ID: I20220512002483 |
| Provider Name | Elizabeth Payment |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1013477751 PECOS PAC ID: 2163757956 Enrollment ID: I20220805000070 |
| Provider Name | Reema Patel |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1699333476 PECOS PAC ID: 2466837117 Enrollment ID: I20220915002065 |
| Provider Name | Saad Ali Khan |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1598260929 PECOS PAC ID: 6002169711 Enrollment ID: I20221004001988 |
| Provider Name | Monjari Gillian |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1265533665 PECOS PAC ID: 4587550876 Enrollment ID: I20230125002283 |
| Provider Name | Theresa Yuh |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1265523930 PECOS PAC ID: 3173576154 Enrollment ID: I20230425003009 |
| Provider Name | Alexander Fernandez |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1063639342 PECOS PAC ID: 7113028838 Enrollment ID: I20230628001779 |
| Provider Name | Sharon Kane |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1194792077 PECOS PAC ID: 4183638059 Enrollment ID: I20230908001406 |
| Provider Name | Mark Girguis |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1477591154 PECOS PAC ID: 1850303165 Enrollment ID: I20230914004167 |
| Provider Name | Meghna Krishnan |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1376781914 PECOS PAC ID: 5092848630 Enrollment ID: I20230915000068 |
| Provider Name | Justin Shafa |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1447612981 PECOS PAC ID: 2264839984 Enrollment ID: I20230929002049 |
| Provider Name | Rakesh S Ahuja |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1538576483 PECOS PAC ID: 9133421571 Enrollment ID: I20240206003917 |
| Provider Name | Lindsey Grandbois |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1720250319 PECOS PAC ID: 4183796782 Enrollment ID: I20240207002344 |
| Provider Name | Ali Raza |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1457553075 PECOS PAC ID: 5890848600 Enrollment ID: I20240212002436 |
| Provider Name | Lisa Ona Ballehr |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1417996018 PECOS PAC ID: 9537063771 Enrollment ID: I20240216000582 |
| Provider Name | Patricia E Sullivan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1467744532 PECOS PAC ID: 6305282401 Enrollment ID: I20240312001214 |
| Provider Name | Johnathan Charles Hays |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1366654162 PECOS PAC ID: 5698825867 Enrollment ID: I20240605000952 |
| Provider Name | Anna Rosa Faso |
|---|---|
| Provider Type | Practitioner - Registered Dietitian Or Nutrition Professional |
| Provider Identifiers | NPI Number: 1982452348 PECOS PAC ID: 0840732822 Enrollment ID: I20240605002516 |
| Provider Name | Maharshi Rajdev |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1427412014 PECOS PAC ID: 0244522175 Enrollment ID: I20240625003187 |
| Provider Name | Michael Tanious |
|---|---|
| Provider Type | Practitioner - Interventional Radiology |
| Provider Identifiers | NPI Number: 1972009249 PECOS PAC ID: 3577894898 Enrollment ID: I20240709001399 |
| Provider Name | John Crow |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1962065300 PECOS PAC ID: 5698216315 Enrollment ID: I20240923000369 |
| Provider Name | Karen Ann Basat Denkov |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1003475294 PECOS PAC ID: 5698206233 Enrollment ID: I20241007001587 |
| Provider Name | Omar Uddin |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1366833204 PECOS PAC ID: 2769733393 Enrollment ID: I20241120000553 |
| Provider Name | Zia Khan |
|---|---|
| Provider Type | Practitioner - Diagnostic Radiology |
| Provider Identifiers | NPI Number: 1790244697 PECOS PAC ID: 7719216381 Enrollment ID: I20241120003964 |
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