Healthcare Provider Details

I. General information

NPI: 1801806351
Provider Name (Legal Business Name): LEO G. NIEDERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY 770 JONES
CHICAGO IL
60612-3244
US

IV. Provider business mailing address

1653 W CONGRESS PKWY 770 JONES
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-1501
  • Fax: 312-563-4159
Mailing address:
  • Phone: 312-942-1501
  • Fax: 312-563-4159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036061069
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: