Healthcare Provider Details

I. General information

NPI: 1225952575
Provider Name (Legal Business Name): MACEO EDMONDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4137 SAUK TRL STE 148
RICHTON PARK IL
60471-1253
US

IV. Provider business mailing address

4137 SAUK TRL STE 148
RICHTON PARK IL
60471-1253
US

V. Phone/Fax

Practice location:
  • Phone: 312-600-3612
  • Fax: 312-847-8405
Mailing address:
  • Phone: 630-806-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.114115
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: