Healthcare Provider Details

I. General information

NPI: 1134485055
Provider Name (Legal Business Name): JOHN G LATALL MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2073 N CLYBOURN AVE
CHICAGO IL
60614-4003
US

IV. Provider business mailing address

2073 N CLYBOURN AVE
CHICAGO IL
60614-4003
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-4016
  • Fax: 773-360-6200
Mailing address:
  • Phone: 773-665-4016
  • Fax: 773-665-0403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number036-084430
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN G LATALL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 773-665-4016