Provider Demographics
NPI:1891708343
Name:XIE, XIAOYUAN (MD)
Entity type:Individual
Prefix:
First Name:XIAOYUAN
Middle Name:
Last Name:XIE
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 1:921 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105360207L00000X
IL036.105360208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105360Medicaid
IL036105360Medicaid