MEDICARE: TYSON STOCK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036140162	IL

General Provider Information

NPI Number	:	1114366788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYSON STOCK D.O.

Provider Business Mailing Address
First Line	:	3000 N HALSTED ST STE 401
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-9268
Country	:	US
Telephone Number	:	773-935-5985
Fax Number	:	773-935-5478

Provider Business Practice Location Address
First Line	:	3000 N HALSTED ST STE 401
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-9268
Country	:	US
Telephone Number	:	773-935-5985
Fax Number	:	773-935-5478

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2013
Last Update Date	:	05/10/2018

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Directions to “ TYSON STOCK D.O.” Practice Location

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