Healthcare Provider Details

I. General information

NPI: 1376620070
Provider Name (Legal Business Name): KEIA KISHELLE HOBBS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEIA KISHELLE CLAY MD

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 W TAYLOR ST
CHICAGO IL
60612-7246
US

IV. Provider business mailing address

1919 W TAYLOR ST
CHICAGO IL
60612-7246
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2914
  • Fax:
Mailing address:
  • Phone: 312-996-2914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006-01397
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-105930
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: