Provider Demographics
NPI:1306096631
Name:DIANE TATE MD
Entity type:Organization
Organization Name:DIANE TATE MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-775-1622
Mailing Address - Street 1:6547 N AVONDALE AVE
Mailing Address - Street 2:SUITE 001
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1573
Mailing Address - Country:US
Mailing Address - Phone:773-775-1622
Mailing Address - Fax:
Practice Address - Street 1:6547 N AVONDALE AVE
Practice Address - Street 2:SUITE 001
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1573
Practice Address - Country:US
Practice Address - Phone:773-775-1622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042759207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042759Medicaid
IL903110Medicare PIN