Provider Demographics
NPI:1336110022
Name:PSARADELLIS, TELLY (MD)
Entity Type:Individual
Prefix:
First Name:TELLY
Middle Name:
Last Name:PSARADELLIS
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 1:2850 S WABASH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2955
Mailing Address - Country:US
Mailing Address - Phone:312-842-4600
Mailing Address - Fax:312-842-8694
Practice Address - Street 1:2850 S WABASH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2955
Practice Address - Country:US
Practice Address - Phone:312-842-4600
Practice Address - Fax:312-842-8694
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113086207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCF2064OtherRAILROAD GROUP
IL036113086Medicaid
P00252879OtherRAILROAD MEDICARE
I19030Medicare UPIN
IL036113086Medicaid
P00252879OtherRAILROAD MEDICARE