Healthcare Provider Details

I. General information

NPI: 1518141365
Provider Name (Legal Business Name): MICHAEL JAMES RADTKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ELDORADO BLVD BLDG 62141
BROOMFIELD CO
80021-3408
US

IV. Provider business mailing address

1870 W GALENA BLVD
AURORA IL
60506-4356
US

V. Phone/Fax

Practice location:
  • Phone: 312-485-0210
  • Fax:
Mailing address:
  • Phone: 630-859-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036116079
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: