Healthcare Provider Details

I. General information

NPI: 1417350414
Provider Name (Legal Business Name): BILLY TATUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1436 W. RANDOLPH 5TH FLOOR
CHICAGO IL
60607
US

IV. Provider business mailing address

1436 W RANDOLPH ST 5TH FLOOR
CHICAGO IL
60607-1405
US

V. Phone/Fax

Practice location:
  • Phone: 312-226-8720
  • Fax: 312-226-8722
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: