Basic Information
| Provider Information | |||||||||
| NPI: | 1356834568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROYAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | REGINA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROYAN STAMM | ||||||||
| OtherFirstName: | REGINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD, MPH | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 N WESTMORELAND RD | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600451658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475356150 | ||||||||
| FaxNumber: | 8475357801 | ||||||||
| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE # MC5068 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737959758 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 125.071795 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036156950 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.