Healthcare Provider Details

I. General information

NPI: 1225521776
Provider Name (Legal Business Name): ELLEN DAILY STEPHEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2018
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 117
CHICAGO IL
60612-3848
US

IV. Provider business mailing address

1725 W HARRISON ST STE 117
CHICAGO IL
60612-3848
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6296
  • Fax:
Mailing address:
  • Phone: 312-942-6296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.072452
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number036.155856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: