Provider Demographics
NPI:1306991310
Name:EGWELE, RICHARD A (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:EGWELE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:EGWELE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 17578
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-0578
Mailing Address - Country:US
Mailing Address - Phone:773-374-2441
Mailing Address - Fax:773-374-7652
Practice Address - Street 1:9135 S EXCHANGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4225
Practice Address - Country:US
Practice Address - Phone:773-374-2441
Practice Address - Fax:773-374-7652
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21607598OtherBLUE CROSS BLUE SHIELD
IL036051741Medicaid
IL21607598OtherBLUE CROSS BLUE SHIELD
ILC42500Medicare UPIN