Healthcare Provider Details

I. General information

NPI: 1043277148
Provider Name (Legal Business Name): RICHARD EDWARD POWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SALUD PEDIATRICS 600 S. RANDALL ROAD STE 220
ALGONQUIN IL
60102
US

IV. Provider business mailing address

1201 S PRAIRIE AVE APT 4604
CHICAGO IL
60605-3553
US

V. Phone/Fax

Practice location:
  • Phone: 847-854-9402
  • Fax: 847-854-9403
Mailing address:
  • Phone: 312-203-0708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036092870
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier036092870
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: