Healthcare Provider Details

I. General information

NPI: 1093719569
Provider Name (Legal Business Name): CHERYL E WOODSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2005
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/30/2006

III. Provider practice location address

316 DIXIE HWY
CHICAGO HEIGHTS IL
60411-1770
US

IV. Provider business mailing address

25020 NETWORK PL
CHICAGO IL
60673-1250
US

V. Phone/Fax

Practice location:
  • Phone: 708-709-9200
  • Fax: 773-767-3944
Mailing address:
  • Phone: 708-709-9200
  • Fax: 773-767-3944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036076317
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: