Basic Information
| Provider Information | |||||||||
| NPI: | 1154616928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDRIK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | MSN, RN, CWOCN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2248 GROVE AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604022201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087887340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 SOUTH CALIFORNIA AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735422000 | ||||||||
| FaxNumber: | 7732575205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2011 | ||||||||
| LastUpdateDate: | 06/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 309.000463 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.