Provider Demographics
NPI:1306899216
Name:CHAFFIN, EDITH MERLE (MD)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:MERLE
Last Name:CHAFFIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 S STEWART AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-3116
Mailing Address - Country:US
Mailing Address - Phone:773-487-3017
Mailing Address - Fax:773-487-3028
Practice Address - Street 1:6307 S STEWART AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3116
Practice Address - Country:US
Practice Address - Phone:773-487-3017
Practice Address - Fax:773-487-3028
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067419207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067419Medicaid
E33649Medicare UPIN