MEDICARE: EDITH MERLE CHAFFIN MD

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician	036067419	IL
2	207Q00000X	Family Medicine Physician	036067419	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306899216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDITH MERLE CHAFFIN MD

Provider Business Mailing Address
First Line	:	6307 S STEWART AVE STE 310
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60621-3116
Country	:	US
Telephone Number	:	773-487-3017
Fax Number	:	773-487-3028

Provider Business Practice Location Address
First Line	:	6307 S STEWART AVE
Second Line	:	SUITE 204
City	:	CHICAGO
State	:	IL
Zip	:	60621-3116
Country	:	US
Telephone Number	:	773-487-3017
Fax Number	:	773-487-3028

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	08/21/2020

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Directions to “ EDITH MERLE CHAFFIN MD” Practice Location

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