Basic Information
| Provider Information | |||||||||
| NPI: | 1679626717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORARIU | ||||||||
| FirstName: | ISTINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5330 W DEVON AVE | ||||||||
| Address2: | STE. #14 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606464108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125050938 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 N RIVER RD | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600161209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472971800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 282E00000X | 036-097205 | IL | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 01635967 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 036097205 | 05 | IL | MEDICAID |