=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992026769
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH ANN GADDE D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2010
-----------------------------------------------------
Last Update Date | 08/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 E CHICAGO AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-227-0097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 E CHICAGO AVE # 9
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085P0229X
-----------------------------------------------------
Taxonomy Name | Pediatric Radiology Physician
-----------------------------------------------------
License Number | 036153126
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | 036.153126
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | OS016627
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 63697-21
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------