Provider Demographics
NPI:1386623460
Name:GHISLANDI, EDWARD VICTOR (MD)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:VICTOR
Last Name:GHISLANDI
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 1:5641 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-2742
Mailing Address - Country:US
Mailing Address - Phone:773-282-2520
Mailing Address - Fax:773-282-7970
Practice Address - Street 1:5641 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-2742
Practice Address - Country:US
Practice Address - Phone:773-282-2520
Practice Address - Fax:773-282-7970
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-39002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL423530Medicare ID - Type Unspecified
D11417Medicare UPIN