Healthcare Provider Details

I. General information

NPI: 1699129858
Provider Name (Legal Business Name): MICHAEL EGGERSTEDT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 550
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

1611 W HARRISON ST STE 550
CHICAGO IL
60612-4861
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6100
  • Fax:
Mailing address:
  • Phone: 312-942-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number036161063
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number036161063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: