Healthcare Provider Details

I. General information

NPI: 1922107952
Provider Name (Legal Business Name): MICHAEL WILLIAM EARLEY M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 W CHICAGO AVE
CHICAGO IL
60651-3934
US

IV. Provider business mailing address

3623 W CHICAGO AVE
CHICAGO IL
60651-3934
US

V. Phone/Fax

Practice location:
  • Phone: 773-722-6171
  • Fax: 773-722-7913
Mailing address:
  • Phone: 773-722-6171
  • Fax: 773-722-7913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036067635
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: