Provider Demographics
NPI:1477795839
Name:JUAN CHEDIAK MD
Entity Type:Organization
Organization Name:JUAN CHEDIAK MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNDAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-366-7177
Mailing Address - Street 1:3000 N HALSTED ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5188
Mailing Address - Country:US
Mailing Address - Phone:773-868-0380
Mailing Address - Fax:773-868-0382
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 600
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5188
Practice Address - Country:US
Practice Address - Phone:773-868-0380
Practice Address - Fax:773-868-0382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-048665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048665Medicaid
IL213425OtherMEDICARE
IL363965106OtherBLUE CROSS BLUE SHIELD ILLINOIS
IL363965106OtherBLUE CROSS BLUE SHIELD ILLINOIS