Healthcare Provider Details

I. General information

NPI: 1003131657
Provider Name (Legal Business Name): PAUL OWEN PHELPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 N HALSTED ST STE 200
CHICAGO IL
60614-4365
US

IV. Provider business mailing address

2001 N HALSTED ST STE 200
CHICAGO IL
60614-4365
US

V. Phone/Fax

Practice location:
  • Phone: 312-888-5754
  • Fax: 833-989-2458
Mailing address:
  • Phone: 312-888-5754
  • Fax: 847-657-1860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number036.131388
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: