Healthcare Provider Details

I. General information

NPI: 1730851213
Provider Name (Legal Business Name): GRANT ZHIXUAN ZHAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2021
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

IV. Provider business mailing address

836 W WELLINGTON AVE
CHICAGO IL
60657-5147
US

V. Phone/Fax

Practice location:
  • Phone: 312-766-4949
  • Fax: 312-766-4925
Mailing address:
  • Phone: 312-766-4949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.086016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: