Healthcare Provider Details

I. General information

NPI: 1972469781
Provider Name (Legal Business Name): KIDUS MIRUTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2025
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E 75TH ST
CHICAGO IL
60649-3603
US

IV. Provider business mailing address

1625 E 75TH ST
CHICAGO IL
60649-3603
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7309
  • Fax:
Mailing address:
  • Phone: 773-947-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.088981
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: