Healthcare Provider Details

I. General information

NPI: 1750761359
Provider Name (Legal Business Name): JUAN ROMERO GADDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 07/24/2021
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 N CLARK ST
CHICAGO IL
60626-4097
US

IV. Provider business mailing address

6500 N CLARK ST
CHICAGO IL
60626-4097
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8664
Mailing address:
  • Phone: 733-388-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125067141
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036.145871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: