Healthcare Provider Details

I. General information

NPI: 1235831348
Provider Name (Legal Business Name): KIRK PATRICK CHIU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 224-619-7221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125082486
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.082486
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036177812
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: