Healthcare Provider Details

I. General information

NPI: 1053603613
Provider Name (Legal Business Name): JONATHAN SETH ADELSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 N CLARK ST # 1028
CHICAGO IL
60640-4620
US

IV. Provider business mailing address

4610 N CLARK ST # 1028
CHICAGO IL
60640-4620
US

V. Phone/Fax

Practice location:
  • Phone: 773-747-5500
  • Fax: 773-747-5586
Mailing address:
  • Phone: 773-747-5500
  • Fax: 773-747-5586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number036144161
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036144161
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: