Provider Demographics
NPI:1942261516
Name:CHEN, MELISSA (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 WATERBURY AVE
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5815
Mailing Address - Country:US
Mailing Address - Phone:847-336-0240
Mailing Address - Fax:
Practice Address - Street 1:662 WATERBURY AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5815
Practice Address - Country:US
Practice Address - Phone:847-336-0240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041572207R00000X
IL036.119255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0171100OtherL & I WORKERS COMP
WA8357360Medicaid
WA5411CHOtherREGENCE BLUESHIELD RIDER
WAP00044162OtherRAILROAD MEDICARE
WAP00044162OtherRAILROAD MEDICARE
WAH84474Medicare UPIN