Basic Information
| Provider Information | |||||||||
| NPI: | 1720075740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVRAMIDIS | ||||||||
| FirstName: | JAANA | ||||||||
| MiddleName: | KRISTIINA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778546 | ||||||||
| FaxNumber: | 8473778808 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 BELVIDERE ROAD | ||||||||
| Address2: | |||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778400 | ||||||||
| FaxNumber: | 8479845619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 036-094588 | IL | N | Other Service Providers | Specialist | 174400000X | 036.094588 | IL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 036094588 | 05 | IL | MEDICAID |