Healthcare Provider Details

I. General information

NPI: 1114548922
Provider Name (Legal Business Name): PAUL EAPEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 07/08/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S PAULINA ST SUITE 403
CHICAGO IL
60612
US

IV. Provider business mailing address

620 S PAULINA ST SUITE 403
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 312-942-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125080857
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: