Healthcare Provider Details

I. General information

NPI: 1679617872
Provider Name (Legal Business Name): EDWARD PASSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068
US

IV. Provider business mailing address

PO BOX 1447
MORTON GROVE IL
60053-7447
US

V. Phone/Fax

Practice location:
  • Phone: 847-823-9800
  • Fax: 847-823-9801
Mailing address:
  • Phone: 847-823-9800
  • Fax: 847-823-9801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036066133
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036066133
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number036066133
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: