Healthcare Provider Details

I. General information

NPI: 1871421545
Provider Name (Legal Business Name): VINCENT JAMES EDWARDS SR. DR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E ONTARIO ST
CHICAGO IL
60611-2806
US

IV. Provider business mailing address

230 E OHIO ST
CHICAGO IL
60611-3265
US

V. Phone/Fax

Practice location:
  • Phone: 872-366-8755
  • Fax:
Mailing address:
  • Phone: 872-366-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: