Healthcare Provider Details

I. General information

NPI: 1790479806
Provider Name (Legal Business Name): TIFFANY GAE EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18127 WILLIAM ST
LANSING IL
60438-3921
US

IV. Provider business mailing address

6308 ALLEMONG DR
MATTESON IL
60443-1097
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-0200
  • Fax:
Mailing address:
  • Phone: 773-937-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036177246
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: