MEDICARE: MR. ROBERT CHANNON M.D.

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	2084P0800X	Psychiatry Physician		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01621679	OTHER	IL	BCBS OF IL

General Provider Information

NPI Number	:	1568445146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT CHANNON M.D.

Provider Business Mailing Address
First Line	:	2525 S MICHIGAN AVE
Second Line	:	B-390
City	:	CHICAGO
State	:	IL
Zip	:	60616-2333
Country	:	US
Telephone Number	:	312-567-6691
Fax Number	:	312-328-7895

Provider Business Practice Location Address
First Line	:	2525 S MICHIGAN AVE
Second Line	:	B-390
City	:	CHICAGO
State	:	IL
Zip	:	60616-2333
Country	:	US
Telephone Number	:	312-567-6691
Fax Number	:	312-328-7895

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	07/08/2007

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Directions to “ MR. ROBERT CHANNON M.D.” Practice Location

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