Healthcare Provider Details

I. General information

NPI: 1104073386
Provider Name (Legal Business Name): ADAM CHRISTOPHER ROBERT DANIELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068
US

IV. Provider business mailing address

5334 S WOODROW ST STE 100
MURRAY UT
84107-5838
US

V. Phone/Fax

Practice location:
  • Phone: 847-723-2210
  • Fax:
Mailing address:
  • Phone: 801-284-1702
  • Fax: 801-266-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number10237201-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number10237201-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.054103
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: