Healthcare Provider Details

I. General information

NPI: 1083315212
Provider Name (Legal Business Name): TYUS TEMPLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date: 06/10/2024
Reactivation Date: 06/18/2024

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-3803
  • Fax:
Mailing address:
  • Phone: 773-989-3803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: