Provider Demographics
NPI:1831124585
Name:PERSELL, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:PERSELL
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 1:750 N LAKE SHORE DR FL 10TH
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4550
Mailing Address - Country:US
Mailing Address - Phone:312-503-6464
Mailing Address - Fax:
Practice Address - Street 1:675 N SAINT CLAIR ST STE 18-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5929
Practice Address - Country:US
Practice Address - Phone:312-695-8630
Practice Address - Fax:312-695-2857
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H43528Medicare UPIN