Healthcare Provider Details

I. General information

NPI: 1891922886
Provider Name (Legal Business Name): IAN ROBERT MACUMBER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PARKWAY
CHICAGO IL
60612
US

IV. Provider business mailing address

607 W WRIGHTWOOD AVE APT 215
CHICAGO IL
60614-2542
US

V. Phone/Fax

Practice location:
  • Phone: 978-846-1443
  • Fax:
Mailing address:
  • Phone: 978-846-1443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-056527
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: