Healthcare Provider Details

I. General information

NPI: 1902224074
Provider Name (Legal Business Name): DANIEL CHAN MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST STE 400
PEORIA IL
61606-2036
US

IV. Provider business mailing address

1001 MAIN ST STE 400
PEORIA IL
61606-2036
US

V. Phone/Fax

Practice location:
  • Phone: 309-308-3350
  • Fax: 309-308-3351
Mailing address:
  • Phone: 309-308-3350
  • Fax: 309-308-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number036.156546
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: