Provider Demographics
NPI:1679550545
Name:MELIAN, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MELIAN
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 1:2160 S FIRST AVE
Mailing Address - Street 2:(MAGUIRE CENTER, RM. 2944)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-2575
Mailing Address - Fax:708-216-5924
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(MAGUIRE CENTER, RM. 2944)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-2575
Practice Address - Fax:708-216-5924
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360868342085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36086834Medicaid
IL330540Medicare ID - Type Unspecified
IL36086834Medicaid