Healthcare Provider Details

I. General information

NPI: 1568048015
Provider Name (Legal Business Name): ADAM LAWRENCE ZACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7435 W TALCOTT AVE
CHICAGO IL
60631-3707
US

IV. Provider business mailing address

7435 W TALCOTT AVE
CHICAGO IL
60631-3707
US

V. Phone/Fax

Practice location:
  • Phone: 773-990-7921
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036166835
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036166835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: