Basic Information
| Provider Information | |||||||||
| NPI: | 1720080534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATRICIO | ||||||||
| FirstName: | MYRNA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1431 N WESTERN AVE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606227712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732762272 | ||||||||
| FaxNumber: | 7732762399 | ||||||||
| Practice Location | |||||||||
| Address1: | 1431 N WESTERN AVE | ||||||||
| Address2: | #101 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606221797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732762272 | ||||||||
| FaxNumber: | 7732762399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036092352 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036092352 | 05 | IL | MEDICAID |