Healthcare Provider Details

I. General information

NPI: 1548534027
Provider Name (Legal Business Name): ROGER TERAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-4503
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-3630
  • Fax: 773-753-8301
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.083178
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036182493
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: