Healthcare Provider Details

I. General information

NPI: 1508987355
Provider Name (Legal Business Name): EDWAED WELDON FOWLER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W HARRISON ST
CHICAGO IL
60612-3714
US

IV. Provider business mailing address

1122 NEWBERRY AVE
LA GRANGE PARK IL
60526-1249
US

V. Phone/Fax

Practice location:
  • Phone: 773-869-7488
  • Fax:
Mailing address:
  • Phone: 708-415-0035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: