Provider Demographics
NPI:1780760819
Name:CHARLES E KAEGI, M.D. SC
Entity type:Organization
Organization Name:CHARLES E KAEGI, M.D. SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:KAEGI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-282-4387
Mailing Address - Street 1:4801 W PETERSON AVE
Mailing Address - Street 2:SUITE 217
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5713
Mailing Address - Country:US
Mailing Address - Phone:773-282-4387
Mailing Address - Fax:773-282-4574
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5713
Practice Address - Country:US
Practice Address - Phone:773-282-4387
Practice Address - Fax:773-282-4574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360557372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055737Medicaid
ILD13880Medicare UPIN
IL036055737Medicaid