NPIMap

Individual provider Active NPI

Ismene Potakis, PA-C

  • Physician Assistant
  • Chicago, IL
National Provider Identifier
1215217286
Registry record updated Aug 24, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
085004104 Issued in IL
Practice address
675 N Saint Clair St Ste 14-200
Chicago, IL 60611-5966
Phone
(126) 957-5423
Fax
(312) 695-5462
NPI assigned
Aug 23, 2011
Sex
Female
Sole proprietor
No

Organizations & group practices 18

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2011
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Northwestern Medical Faculty Foundation 4,386 clinicians

Practice addresses (Care Compare)

675 N Saint Clair St
Chicago, IL 60611-5975

675 N St Clair
Chicago, IL 60611-5975

676 N Saint Clair
Chicago, IL 60611-2927

676 N Saint Clair St
Chicago, IL 60611-2927

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Medicare enrollment records 1

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
I20150219002456 IL Practitioner - Physician Assistant 8628393329 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
085004104ILMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Northwestern Medical Faculty Foundation CurrentSince Apr 17, 2021 Accepting new patients
Northwestern Medical Faculty Foundation CurrentSince Apr 17, 2021 Accepting new patients
Central Dupage Physician Group Past Accepting new patients
Center for Women Past Accepting new patients
A-1 Medical Imaging Past Accepting new patients

Locations

Dept 5777
Carol Stream, IL 60122

675 N Saint Clair St
Ste 14-200
Chicago, IL 60611
Phone (312) 695-7382

660 N Westmoreland Rd
#302
Lake Forest, IL 60045

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 085004104 IL Primary

Addresses

NPPES NPI Registry

Primary practice location

675 N Saint Clair St Ste 14-200
Chicago, IL 60611-5966

Mailing address

675 N Saint Clair St Ste 14-200
Chicago, IL 60611-5966
Phone (312) 695-7542

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Aug 24, 2021.

{
    "created_epoch": "1314057600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1629763200000",
    "number": "1215217286",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "675 N SAINT CLAIR ST STE 14-200",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606115966",
            "telephone_number": "312-695-7542",
            "fax_number": "126-955-4623"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "675 N SAINT CLAIR ST STE 14-200",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606115966",
            "telephone_number": "126-957-5423",
            "fax_number": "312-695-5462"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "POTAKIS",
        "first_name": "ISMENE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-08-23",
        "last_updated": "2021-08-24",
        "certification_date": "2021-08-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085004104",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.