Basic Information
| Provider Information | |||||||||
| NPI: | 1508009416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZEGREAN | ||||||||
| FirstName: | ANCA | ||||||||
| MiddleName: | IOANA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 210 S DESPLAINES ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606615500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126542720 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1272 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475497222 | ||||||||
| FaxNumber: | 8475497260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2009 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25268 | WV | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | RE9310001 | 01 | WV | GROUP ORGANIZATION PTAN | OTHER | 3810026117 | 05 | WV | MEDICAID | 1295720449 | 01 | WV | GROUP ORGANIZATION NPI | OTHER | 4000438000 | 01 | WV | GROUP ORGANIZATION MEDICAID NUMBER | OTHER | WV2871A | 01 | WV | MEDICARE PTAN | OTHER |