Provider Demographics
NPI:1306108139
Name:DRIES, ALISSA DANIELLE (MD)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:DANIELLE
Last Name:DRIES
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 1:2334 N SOUTHPORT AVE
Mailing Address - Street 2:UNIT 2R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8355
Mailing Address - Country:US
Mailing Address - Phone:262-391-7039
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:SUITE 720 PAVILLION
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-6610
Practice Address - Fax:312-942-6606
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125061467207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology