Healthcare Provider Details

I. General information

NPI: 1790701472
Provider Name (Legal Business Name): ENDALE T MEKONEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 E 93RD ST STE 339
CHICAGO IL
60617-3916
US

IV. Provider business mailing address

4425 MADISON ST
SKOKIE IL
60076-2627
US

V. Phone/Fax

Practice location:
  • Phone: 773-978-4330
  • Fax:
Mailing address:
  • Phone: 708-479-6522
  • Fax: 708-479-6597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: