Healthcare Provider Details

I. General information

NPI: 1669442521
Provider Name (Legal Business Name): CONSTANCE N BLADE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 N HALSTED ST SUITE 402
CHICAGO IL
60642
US

IV. Provider business mailing address

1460 N HALSTED ST SUITE 402
CHICAGO IL
60642
US

V. Phone/Fax

Practice location:
  • Phone: 312-279-8900
  • Fax: 312-981-6312
Mailing address:
  • Phone: 312-279-8900
  • Fax: 312-981-6312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036062172
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: