Provider Demographics
NPI:1194804245
Name:DIS, EFFIE (MD)
Entity type:Individual
Prefix:DR
First Name:EFFIE
Middle Name:
Last Name:DIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 BELLWOOD LN
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1529
Mailing Address - Country:US
Mailing Address - Phone:847-657-9396
Mailing Address - Fax:847-657-8796
Practice Address - Street 1:309 E DUNDEE RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3107
Practice Address - Country:US
Practice Address - Phone:847-392-8080
Practice Address - Fax:847-279-0595
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL687520Medicare ID - Type Unspecified
ILD14902Medicare UPIN