Healthcare Provider Details

I. General information

NPI: 1457764177
Provider Name (Legal Business Name): PATRICK KEVIN ENNIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S CALIFORNIA AVE
CHICAGO IL
60608-5107
US

IV. Provider business mailing address

1900 W POLK ST STE 1221
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 773-674-7488
  • Fax:
Mailing address:
  • Phone: 312-864-0451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036141466
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: