Healthcare Provider Details

I. General information

NPI: 1902899792
Provider Name (Legal Business Name): GUY R ABDERHOLDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 ORCHARD ST
ANTIOCH IL
60002-3107
US

IV. Provider business mailing address

543 ORCHARD ST
ANTIOCH IL
60002-3107
US

V. Phone/Fax

Practice location:
  • Phone: 847-395-3322
  • Fax: 847-395-0921
Mailing address:
  • Phone: 847-395-3322
  • Fax: 847-395-0921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33453020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-084853
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: