Basic Information
| Provider Information | |||||||||
| NPI: | 1114902632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILENKOVICH | ||||||||
| FirstName: | DANICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8558 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193927084 | ||||||||
| FaxNumber: | 2197036854 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 W POLK ST STE G1 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606052083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129223011 | ||||||||
| FaxNumber: | 3129225860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 10/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01084845A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036092363 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 300043509 | 05 | IN | MEDICAID | 01621679 | 01 | IL | BCBS OF IL | OTHER | 036092363 | 05 | IL | MEDICAID |