Healthcare Provider Details

I. General information

NPI: 1225337496
Provider Name (Legal Business Name): MEGHAN KATHLEEN EDMUNDSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2011
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3047 N LINCOLN AVE UNIT 400
CHICAGO IL
60657-4274
US

IV. Provider business mailing address

3047 N LINCOLN AVE UNIT 400
CHICAGO IL
60657-4274
US

V. Phone/Fax

Practice location:
  • Phone: 773-505-1967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8436531
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036141758
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036141758
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: