Provider Demographics
NPI:1316916190
Name:NAM, ELLIS (MD)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:NAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:847-929-1154
Practice Address - Street 1:3000 HALSTED STREET
Practice Address - Street 2:SUITE 525
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-9269
Practice Address - Country:US
Practice Address - Phone:773-433-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106737207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL23441201OtherUNITED HEALTHCARE
IL036106737Medicaid
IL1634061OtherBLUE CROSS BLUE SHIELD
IL681033OtherADVOCATE
ILP00114315OtherRAILROAD MEDICARE
IL1634061OtherBLUE CROSS BLUE SHIELD
ILH70093Medicare UPIN