Basic Information
| Provider Information | |||||||||
| NPI: | 1043202567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STERN | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | LYONS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 N FAIRBANKS CT | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124723173 | ||||||||
| FaxNumber: | 3124723176 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 W OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605591419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304326200 | ||||||||
| FaxNumber: | 6304326660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01058075A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 01058075A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 036-108619 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 90001358 | 01 | IL | BCBSIL | OTHER | 200501020 | 05 | IN | MEDICAID | 036108619 | 05 | IL | MEDICAID |