Provider Demographics
NPI:1336702125
Name:AUF DEM GRABEN, EDGAR
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:AUF DEM GRABEN
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 1:6493 N NORTHWEST HWY APT 409
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1892
Mailing Address - Country:US
Mailing Address - Phone:708-774-4946
Mailing Address - Fax:
Practice Address - Street 1:100 N RIVER RD STE G122
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1209
Practice Address - Country:US
Practice Address - Phone:847-581-0800
Practice Address - Fax:847-410-4910
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054-0359241835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054-035924OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION