Healthcare Provider Details

I. General information

NPI: 1679969182
Provider Name (Legal Business Name): GREG D EWERT MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MICHIGAN AVE SUITE 805
CHICAGO IL
60604-2402
US

IV. Provider business mailing address

200 S MICHIGAN AVE SUITE 805
CHICAGO IL
60604-2402
US

V. Phone/Fax

Practice location:
  • Phone: 312-922-3815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: GREG EWERT
Title or Position: OWNER
Credential:
Phone: 312-922-4734