Provider Demographics
NPI:1104005966
Name:EUGENE CHUKUDEBELU MD SC
Entity type:Organization
Organization Name:EUGENE CHUKUDEBELU MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUKUDEBELU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-723-9500
Mailing Address - Street 1:8259 S SAINT LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-5009
Mailing Address - Country:US
Mailing Address - Phone:773-723-9500
Mailing Address - Fax:773-224-4403
Practice Address - Street 1:326 W 64TH ST
Practice Address - Street 2:SUITE 318
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3114
Practice Address - Country:US
Practice Address - Phone:773-723-9500
Practice Address - Fax:773-224-4403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21607396OtherBLUE CROSS/BLUE SHIELD
IL21607396OtherBLUE CROSS/BLUE SHIELD
IL213279Medicare PIN