MEDICARE: ALEXANDER KYLE TATUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071.010516	IL

General Provider Information

NPI Number	:	1316435423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDER KYLE TATUM

Provider Business Mailing Address
First Line	:	5412 N CLARK ST STE 212
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1273
Country	:	US
Telephone Number	:	434-284-3806
Fax Number	:

Provider Business Practice Location Address
First Line	:	5412 N CLARK ST STE 212
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1273
Country	:	US
Telephone Number	:	773-257-3606
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2018
Last Update Date	:	02/02/2026

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