Healthcare Provider Details

I. General information

NPI: 1861384513
Provider Name (Legal Business Name): EDUARDO J CISNEROS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 REVERE DR STE 200
NORTHBROOK IL
60062-8000
US

IV. Provider business mailing address

4824 N TRIPP AVE
CHICAGO IL
60630-2721
US

V. Phone/Fax

Practice location:
  • Phone: 312-600-3991
  • Fax: 630-473-2232
Mailing address:
  • Phone: 312-320-1971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041524344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: