Provider Demographics
NPI:1235634775
Name:EDWARDS, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E HURON ST STE 16-738
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3055
Mailing Address - Country:US
Mailing Address - Phone:312-926-5924
Mailing Address - Fax:312-926-6134
Practice Address - Street 1:251 E HURON ST STE 16-738
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3055
Practice Address - Country:US
Practice Address - Phone:312-926-5924
Practice Address - Fax:312-926-6134
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036153768208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program