Healthcare Provider Details

I. General information

NPI: 1538666904
Provider Name (Legal Business Name): ANDRE ISAAC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date: 11/16/2018
Reactivation Date: 11/28/2018

III. Provider practice location address

ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL 225 EAST CHICAGO AVE
CHICAGO IL
60611
US

IV. Provider business mailing address

1936 N. CLARK ST , APT 503
CHICAGO IL
60614
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4000
  • Fax:
Mailing address:
  • Phone: 312-871-7934
  • 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: