Healthcare Provider Details

I. General information

NPI: 1649965997
Provider Name (Legal Business Name): CHIDUBEM JUSTICE IKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 W POLK ST
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-9725
  • Fax: 312-864-9725
Mailing address:
  • Phone: 312-864-0000
  • Fax: 312-864-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125081165
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: