Provider Demographics
NPI:1598869224
Name:ANDREW AGEN DAVIS, MD SC
Entity Type:Organization
Organization Name:ANDREW AGEN DAVIS, MD SC
Other - Org Name:ANDY AGEN DAVIS, MD SC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:AGEN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-874-7711
Mailing Address - Street 1:8541 SOUTH STATE STREET
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619
Mailing Address - Country:US
Mailing Address - Phone:773-874-7711
Mailing Address - Fax:773-874-4721
Practice Address - Street 1:8541 SO STATE STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619
Practice Address - Country:US
Practice Address - Phone:773-874-7711
Practice Address - Fax:773-874-4721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054434207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054434Medicaid
IL214044Medicare PIN
D13985Medicare UPIN
IL036054434Medicaid