Provider Demographics
NPI:1245373703
Name:CHAN, EDIE YEE
Entity type:Individual
Prefix:
First Name:EDIE
Middle Name:YEE
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-4252
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3833
Practice Address - Country:US
Practice Address - Phone:312-942-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109245208600000X, 204F00000X
WAMD00045000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
335890OtherINTERNAL ID-MOTOR VEHICLE ID
WA8430654Medicaid
335890OtherINTERNAL ID-MOTOR VEHICLE ID
8853924Medicare ID - Type Unspecified