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Individual
MARY J MIKHAILOV
Active
Individual
MARY J MIKHAILOV
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036078879
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0222075
BLUE CROSS GROUP NUMBER
IL
05
—
036078879
—
IL
01
—
363149833
TAX IDENTIFICATION NUMBER
IL
01
—
3631498336019001
CDPG HFS PAYEE ID
IL
01
—
548190001
MEDICARE INDIVIDUAL PTAN
IL
Enumeration date
07/05/2006
Last updated
11/03/2014
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