Basic Information
Provider Information | |||||||||
NPI: | 1003892043 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DELIS | ||||||||
FirstName: | CONSTANTINE | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 210 S DESPLAINES ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606615500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3126542700 | ||||||||
FaxNumber: | 3126549930 | ||||||||
Practice Location | |||||||||
Address1: | 1111 SUPERIOR ST | ||||||||
Address2: | SUITE 203 | ||||||||
City: | MELROSE PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 601604138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083381780 | ||||||||
FaxNumber: | 7083381790 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2005 | ||||||||
LastUpdateDate: | 12/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036092711 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 01615184 | 01 | IL | BCBS | OTHER | 036092711 | 05 | IL |   | MEDICAID | 01621679 | 01 | IL | BCBS OF IL | OTHER |