Provider Demographics
NPI:1144229865
Name:DAVID R EDELSTEIN MD SC
Entity Type:Organization
Organization Name:DAVID R EDELSTEIN MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-332-3699
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-332-3699
Mailing Address - Fax:312-332-3698
Practice Address - Street 1:1917 WESTLEIGH DR
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-7612
Practice Address - Country:US
Practice Address - Phone:312-332-3699
Practice Address - Fax:312-332-3698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0476562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
21606223OtherBLUE CROSS OF ILLINOIS
487260Medicare ID - Type Unspecified
C42246Medicare UPIN