Provider Demographics
NPI:1942392055
Name:HARVEY, WALDO EMERSON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALDO
Middle Name:EMERSON
Last Name:HARVEY
Suffix:JR
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 1:1020 S 22ND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-2504
Mailing Address - Country:US
Mailing Address - Phone:708-704-4532
Mailing Address - Fax:773-525-1900
Practice Address - Street 1:3000 N HALSTED
Practice Address - Street 2:SUITE 303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5190
Practice Address - Country:US
Practice Address - Phone:773-525-1900
Practice Address - Fax:773-525-1911
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623742OtherBLUE CROSS BLUE SHIELD
ILL78710Medicare PIN
ILD16578Medicare UPIN
IL1623742OtherBLUE CROSS BLUE SHIELD