Healthcare Provider Details

I. General information

NPI: 1174226195
Provider Name (Legal Business Name): JUSTIN CHEDIAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7617 NORTH AVE
RIVER FOREST IL
60305-1133
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 888-584-7888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036181600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: