Healthcare Provider Details

I. General information

NPI: 1487989083
Provider Name (Legal Business Name): JULIUS CHUCKS AJIDE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 1ST ST SUITE 703
HIGHLAND PARK IL
60035-3200
US

IV. Provider business mailing address

161 PROVIDENCE DR
MATTESON IL
60443-1396
US

V. Phone/Fax

Practice location:
  • Phone: 847-433-1539
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209007843
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: