Basic Information
Provider Information | |||||||||
NPI: | 1235114604 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JUIRIS | ||||||||
FirstName: | TAHIRA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MALIK | ||||||||
OtherFirstName: | TAHIRA | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1840 GREEN BAY RD | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 600353110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479845300 | ||||||||
FaxNumber: | 8476818313 | ||||||||
Practice Location | |||||||||
Address1: | 1840 GREEN BAY RD | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 600353110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479845300 | ||||||||
FaxNumber: | 8476818313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2005 | ||||||||
LastUpdateDate: | 04/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036106084 | IL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 036106084 | 05 | IL |   | MEDICAID |