Healthcare Provider Details

I. General information

NPI: 1407540040
Provider Name (Legal Business Name): CHIDERA MGBUDEM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 ROOSEVELT RD STE A
GLEN ELLYN IL
60137-5618
US

IV. Provider business mailing address

285 ROOSEVELT RD STE A
GLEN ELLYN IL
60137-5618
US

V. Phone/Fax

Practice location:
  • Phone: 630-469-0045
  • Fax: 630-469-0645
Mailing address:
  • Phone: 630-469-0045
  • Fax: 630-469-0645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351050734
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036181332
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: