Provider Demographics
NPI:1295794345
Name:CHEN, MAO H (MD)
Entity type:Individual
Prefix:
First Name:MAO
Middle Name:H
Last Name:CHEN
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 1:331 VINE ST
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3133
Mailing Address - Country:US
Mailing Address - Phone:773-258-8090
Mailing Address - Fax:773-481-6542
Practice Address - Street 1:5600 W. ADDISON ST.
Practice Address - Street 2:SUITE 206
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4469
Practice Address - Country:US
Practice Address - Phone:773-258-8090
Practice Address - Fax:773-481-6542
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036051346207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051346OtherLICENSE #
IL036051346Medicaid
IL110121944OtherRAILROAD MEDICARE PROVIDER #
IL21607181OtherBCBS PROVIDER #
ILD13179Medicare UPIN
IL494032Medicare PIN