Healthcare Provider Details

I. General information

NPI: 1730411489
Provider Name (Legal Business Name): ARIEL OMAR CHAVEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST STE 850
CHICAGO IL
60611-3124
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 850
CHICAGO IL
60611-3124
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-6180
  • Fax: 312-695-6189
Mailing address:
  • Phone: 312-695-6180
  • Fax: 312-695-6189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003644
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: