Healthcare Provider Details

I. General information

NPI: 1013029511
Provider Name (Legal Business Name): ETHAN MICHAEL MEISEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E ONTARIO ST SUITE 925
CHICAGO IL
60611-3468
US

IV. Provider business mailing address

2001 BUTTERFIELD RD SUITE 300
DOWNERS GROVE IL
60515-1050
US

V. Phone/Fax

Practice location:
  • Phone: 312-573-0614
  • Fax: 312-573-0694
Mailing address:
  • Phone: 630-725-2832
  • Fax: 877-489-5993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH95343
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.123753
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: