Basic Information
| Provider Information | |||||||||
| NPI: | 1194136242 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SACKEIM | ||||||||
| FirstName: | MARYL | ||||||||
| MiddleName: | GOLDBERG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5841 S MARYLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737021000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE # MC2050 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737021000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2014 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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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 | 390200000X | MT206760 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | 036145597 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.