Healthcare Provider Details

I. General information

NPI: 1639458128
Provider Name (Legal Business Name): ADRIENNE M. EDGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2971 W ALGONQUIN RD SUITE 105
ALGONQUIN IL
60102-9406
US

IV. Provider business mailing address

2971 W ALGONQUIN RD SUITE 105
ALGONQUIN IL
60102-9406
US

V. Phone/Fax

Practice location:
  • Phone: 847-854-5490
  • Fax: 847-854-8257
Mailing address:
  • Phone: 847-854-5490
  • Fax: 847-854-8257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036101735
License Number StateIL

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: