Provider Demographics
NPI:1154712784
Name:EDP OF ILLINOIS P.C
Entity type:Organization
Organization Name:EDP OF ILLINOIS P.C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARIBAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-736-8963
Mailing Address - Street 1:141 W JACKSON BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3048
Mailing Address - Country:US
Mailing Address - Phone:312-800-1270
Mailing Address - Fax:
Practice Address - Street 1:195 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DUPO
Practice Address - State:IL
Practice Address - Zip Code:62239-1347
Practice Address - Country:US
Practice Address - Phone:312-800-1270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-18
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0016561223S0112X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty