Healthcare Provider Details

I. General information

NPI: 1164917720
Provider Name (Legal Business Name): MR.OAK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 W 79TH ST
CHICAGO IL
60652-1430
US

IV. Provider business mailing address

1629 S PRAIRIE AVE UNIT 1108
CHICAGO IL
60616-5059
US

V. Phone/Fax

Practice location:
  • Phone: 312-259-8555
  • Fax: 773-978-0705
Mailing address:
  • Phone: 312-259-8555
  • Fax: 773-978-0705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN SMITH
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 312-259-8555