Provider Demographics
NPI:1245247634
Name:DAVIS, ANDREW AGEN (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:AGEN
Last Name:DAVIS
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 1:8541 S STATE ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-5665
Mailing Address - Country:US
Mailing Address - Phone:773-874-7711
Mailing Address - Fax:773-874-4721
Practice Address - Street 1:8541 S STATE ST
Practice Address - Street 2:SUITE 8
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-5665
Practice Address - Country:US
Practice Address - Phone:773-874-7711
Practice Address - Fax:773-874-4721
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054434207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054434Medicaid
IL214044Medicare PIN
IL036054434Medicaid
IL619390Medicare PIN