Provider Demographics
NPI:1013029511
Name:MEISEL, ETHAN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:MICHAEL
Last Name:MEISEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1050
Mailing Address - Country:US
Mailing Address - Phone:630-725-2832
Mailing Address - Fax:877-489-5993
Practice Address - Street 1:211 E ONTARIO ST
Practice Address - Street 2:SUITE 925
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3468
Practice Address - Country:US
Practice Address - Phone:312-573-0614
Practice Address - Fax:312-573-0694
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAH95343207P00000X
IL036.123753208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA171006162AMedicaid
GA171006162BMedicaid
ILP01186845OtherMEDICARE RAILROAD INDIVIDUAL PTAN
IL789510008Medicare PIN
ILP01186845OtherMEDICARE RAILROAD INDIVIDUAL PTAN
CAH95343Medicare UPIN