Healthcare Provider Details

I. General information

NPI: 1780380113
Provider Name (Legal Business Name): KYLE JOHN ROUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 09/02/2023
Certification Date: 09/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E SUPERIOR ST STE 9-900
CHICAGO IL
60611-4494
US

IV. Provider business mailing address

420 E SUPERIOR ST STE 9-900
CHICAGO IL
60611-4494
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-7975
  • Fax:
Mailing address:
  • Phone: 312-503-7975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.082039
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: