Healthcare Provider Details

I. General information

NPI: 1114366788
Provider Name (Legal Business Name): TYSON STOCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N HALSTED ST STE 401
CHICAGO IL
60657-9268
US

IV. Provider business mailing address

3000 N HALSTED ST STE 401
CHICAGO IL
60657-9268
US

V. Phone/Fax

Practice location:
  • Phone: 773-935-5985
  • Fax: 773-935-5478
Mailing address:
  • Phone: 773-935-5985
  • Fax: 773-935-5478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036140162
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: