Healthcare Provider Details

I. General information

NPI: 1962993238
Provider Name (Legal Business Name): DR. JUSTIN JIE CHEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE STE F602
CHICAGO IL
60625-8564
US

IV. Provider business mailing address

5215 N CALIFORNIA AVE STE F602
CHICAGO IL
60625-8564
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-3627
  • Fax: 773-878-0985
Mailing address:
  • Phone: 773-878-3627
  • Fax: 773-878-0985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036155255
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: