Provider Demographics
NPI:1376527879
Name:AHN, PHILLIP (MD)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2525 S MICHIGAN AVE
Mailing Address - Street 2:B-390
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2333
Mailing Address - Country:US
Mailing Address - Phone:312-567-6691
Mailing Address - Fax:312-328-7895
Practice Address - Street 1:4321 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4008
Practice Address - Country:US
Practice Address - Phone:773-585-2410
Practice Address - Fax:773-284-0913
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089338207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01621679OtherBCBS OF IL
IL036089338 / 02Medicaid
IL205737OtherMEDICARE PTAN
IL205737OtherMEDICARE PTAN