=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174018899
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER SAUNDERS DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 10/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5346 N CLARK ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-293-8880
-----------------------------------------------------
Fax | 773-293-8843
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2650 RIDGE AVE STE 1223
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-293-8880
-----------------------------------------------------
Fax | 773-293-8843
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 03615805
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------