Healthcare Provider Details

I. General information

NPI: 1588075451
Provider Name (Legal Business Name): SOLOMON PRIMARY CARE DOCTORS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S CENTRAL AVE 6TH FLOOR
CHICAGO IL
60644-5059
US

IV. Provider business mailing address

7205 BENTLEY AVE
DARIEN IL
60561-4145
US

V. Phone/Fax

Practice location:
  • Phone: 708-854-5579
  • Fax: 773-854-5587
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036084144
License Number StateIL

VIII. Authorized Official

Name: DR. DEENADAYAL GADDAM
Title or Position: PRESIDENT
Credential: M.D
Phone: 708-769-0677