Basic Information
Provider Information | |||||||||
NPI: | 1912992561 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAMBIASE | ||||||||
FirstName: | ELYSE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2740 W FOSTER AVE | ||||||||
Address2: | LL7 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7738788200 | ||||||||
FaxNumber: | 7732934197 | ||||||||
Practice Location | |||||||||
Address1: | 800 AUSTIN ST | ||||||||
Address2: | STE 557 | ||||||||
City: | EVANSTON | ||||||||
State: | IL | ||||||||
PostalCode: | 602023456 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8478692076 | ||||||||
FaxNumber: | 8474753414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2005 | ||||||||
LastUpdateDate: | 04/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036064464 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | 036050081 | 05 | IL |   | MEDICAID |