Healthcare Provider Details

I. General information

NPI: 1922254127
Provider Name (Legal Business Name): ELIZABETH GWINN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE RM 4813CC
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

836 W WELLINGTON AVE RM 4813CC
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5073
  • Fax:
Mailing address:
  • Phone: 773-296-5073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number036-132844
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: