Healthcare Provider Details

I. General information

NPI: 1497749030
Provider Name (Legal Business Name): PRESTON BALDWIN CANNADY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3471 GREEN BAY RD THE CLINICS AT ROSALIND FRANKLIN UNIVERSITY
NORTH CHICAGO IL
60064-3037
US

IV. Provider business mailing address

1937 MADISON AVE
GURNEE IL
60031-6099
US

V. Phone/Fax

Practice location:
  • Phone: 847-473-4357
  • Fax:
Mailing address:
  • Phone: 847-625-9395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: