Provider Demographics
NPI:1104809755
Name:COLEMAN, CEDRIC L (MD)
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:L
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9415 S WESTERN AVE
Mailing Address - Street 2:STE 209
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-6730
Mailing Address - Country:US
Mailing Address - Phone:708-229-1600
Mailing Address - Fax:708-229-1611
Practice Address - Street 1:9415 S WESTERN AVE
Practice Address - Street 2:STE 209
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-6700
Practice Address - Country:US
Practice Address - Phone:708-229-1600
Practice Address - Fax:708-229-1611
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2015-10-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036067164207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067164Medicaid
IL737171Medicare ID - Type Unspecified
C45214Medicare UPIN