Healthcare Provider Details

I. General information

NPI: 1225372311
Provider Name (Legal Business Name): CHICAGOLAND MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E DELAWARE PLACE SUITE 401B
CHICAGO IL
60611-5135
US

IV. Provider business mailing address

1 E DELAWARE PLACE SUITE 401B
CHICAGO IL
60611-5135
US

V. Phone/Fax

Practice location:
  • Phone: 312-337-7968
  • Fax: 312-337-4060
Mailing address:
  • Phone: 312-337-7968
  • Fax: 312-337-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038007889
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL N KAUF
Title or Position: DIRECTOR
Credential: D.C.
Phone: 312-337-7968