Basic Information
Provider Information
NPI: 1033559620
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANGARDICH
FirstName: ANTRANIK
MiddleName:  
NamePrefix:  
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Credential: MD
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Mailing Information
Address1: 1750 WEST HARRISON STREET
Address2: 297 JELKE
City: CHICAGO
State: IL
PostalCode: 60612
CountryCode: US
TelephoneNumber: 3129422552
FaxNumber: 3125632157
Practice Location
Address1: 1750 WEST HARRISON STREET
Address2: 297 JELKE
City: CHICAGO
State: IL
PostalCode: 60612
CountryCode: US
TelephoneNumber: 3129422552
FaxNumber: 3125632157
Other Information
ProviderEnumerationDate: 06/27/2013
LastUpdateDate: 12/12/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
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IsSoleProprietor: Y
IsOrganizationSubpart:  
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AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X036.139873ILY Allopathic & Osteopathic PhysiciansInternal Medicine 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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