Healthcare Provider Details

I. General information

NPI: 1174218846
Provider Name (Legal Business Name): EMILY CUSTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 10
CHICAGO IL
60612-3849
US

IV. Provider business mailing address

1725 W HARRISON ST STE 10
CHICAGO IL
60612-3849
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-7030
  • Fax:
Mailing address:
  • Phone: 312-942-7030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberHS000240L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0361797777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: