Healthcare Provider Details

I. General information

NPI: 1093106700
Provider Name (Legal Business Name): ERIK JOHNSON SIMON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 3C
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

840 S WOOD ST, 440 CSN (MC 718)
CHICAGO IL
60612-4325
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-1700
  • Fax: 312-355-3093
Mailing address:
  • Phone: 312-996-4242
  • 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: