Provider Demographics
NPI:1801003991
Name:ARCHBOLD, EDGAR E (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:E
Last Name:ARCHBOLD
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 1:6917 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:708-749-8190
Mailing Address - Fax:708-749-8190
Practice Address - Street 1:6917 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60408
Practice Address - Country:US
Practice Address - Phone:708-749-8190
Practice Address - Fax:708-749-8190
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069407207Q00000X
IL036-069407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01625394OtherBS
IL036068407Medicaid
IL036068407Medicaid
IL216410Medicare PIN
IL01625394OtherBS