Provider Demographics
NPI:1043277148
Name:POWELL, RICHARD EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDWARD
Last Name:POWELL
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 1:1201 S PRAIRIE AVE APT 4604
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3553
Mailing Address - Country:US
Mailing Address - Phone:312-203-0708
Mailing Address - Fax:
Practice Address - Street 1:SALUD PEDIATRICS
Practice Address - Street 2:600 S. RANDALL ROAD STE 220
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102
Practice Address - Country:US
Practice Address - Phone:847-854-9402
Practice Address - Fax:847-854-9403
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092870208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092870Medicaid
FP6546153OtherDEA
G26094Medicare UPIN