Healthcare Provider Details

I. General information

NPI: 1366869414
Provider Name (Legal Business Name): CHEN YANG KUAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE LOYOLA OUTPATIENT CENTER, 4300
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-6006
  • Fax: 708-216-2683
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125066058
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: