Healthcare Provider Details

I. General information

NPI: 1336110022
Provider Name (Legal Business Name): TELLY PSARADELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 S WABASH AVE SUITE 100
CHICAGO IL
60616-2955
US

IV. Provider business mailing address

2850 S WABASH AVE SUITE 100
CHICAGO IL
60616-2955
US

V. Phone/Fax

Practice location:
  • Phone: 312-842-4600
  • Fax: 312-842-8694
Mailing address:
  • Phone: 312-842-4600
  • Fax: 312-842-8694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036-113086
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: