Healthcare Provider Details

I. General information

NPI: 1477795839
Provider Name (Legal Business Name): JUAN CHEDIAK MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N HALSTED ST SUITE 600
CHICAGO IL
60657-5188
US

IV. Provider business mailing address

3000 N HALSTED ST SUITE 600
CHICAGO IL
60657-5188
US

V. Phone/Fax

Practice location:
  • Phone: 773-868-0380
  • Fax: 773-868-0382
Mailing address:
  • Phone: 773-868-0380
  • Fax: 773-868-0382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036-048665
License Number StateIL

VIII. Authorized Official

Name: MS. ELIZABETH BRUNDAGE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 708-366-7177