Healthcare Provider Details

I. General information

NPI: 1669977302
Provider Name (Legal Business Name): MICHAEL PATRICK TRIPP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-3138
  • Fax:
Mailing address:
  • Phone: 312-942-3138
  • Fax: 202-444-8854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036159250
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: