Healthcare Provider Details

I. General information

NPI: 1255343992
Provider Name (Legal Business Name): EDWARD A MICHALS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

809 S MARSHFIELD AVE 9TH FLOOR (M/C 732)
CHICAGO IL
60612-4305
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-996-7699
  • Fax: 312-996-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01093430A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-082313
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: