Healthcare Provider Details

I. General information

NPI: 1285195016
Provider Name (Legal Business Name): MAXIMILIANO MAGALLANES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 N CALIFORNIA AVE
CHICAGO IL
60625-3645
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 773-293-8878
  • Fax: 773-293-8879
Mailing address:
  • Phone: 847-570-2040
  • Fax: 847-733-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036182419
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberV8677
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number83602
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: