Basic Information
Provider Information | |||||||||
NPI: | 1316351539 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POLI | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | CARLA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 777 PARK AVE W STE B400 | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 600352433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475701700 | ||||||||
FaxNumber: | 8479265393 | ||||||||
Practice Location | |||||||||
Address1: | 777 PARK AVE W STE B400 | ||||||||
Address2: |   | ||||||||
City: | HIGHLAND PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 600352433 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475701700 | ||||||||
FaxNumber: | 8479265393 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2014 | ||||||||
LastUpdateDate: | 08/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 036141146 | IL | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
ID | Type | State | Issuer | Description | 428828401 | 05 | TX |   | MEDICAID | 428828402 | 01 | TX | CSHCN | OTHER |