Healthcare Provider Details

I. General information

NPI: 1578121877
Provider Name (Legal Business Name): KELLY HUTCHISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E HIGGINS RD STE 102
ELK GROVE VILLAGE IL
60007-1417
US

IV. Provider business mailing address

450 E HIGGINS RD STE 102
ELK GROVE VILLAGE IL
60007-1417
US

V. Phone/Fax

Practice location:
  • Phone: 847-690-9825
  • Fax: 847-690-9824
Mailing address:
  • Phone: 847-690-9825
  • Fax: 847-690-9824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number3000242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: