Basic Information
| Provider Information | |||||||||
| NPI: | 1235100140 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHAEL J. ATHANS, PH.D. AND ASSOCIATES, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 MAIN ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600684060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478234444 | ||||||||
| FaxNumber: | 8478234456 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 MAIN ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600684060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478234444 | ||||||||
| FaxNumber: | 8478234456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 11/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | ATHANS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8478234444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071003398 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 01633134 | 01 | IL | BLUE CROSS PROVIDER NUMBE | OTHER |