Basic Information
Provider Information | |||||||||
NPI: | 1245373703 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHAN | ||||||||
FirstName: | EDIE | ||||||||
MiddleName: | YEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1653 W CONGRESS PKWY | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606123833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129424252 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1653 W CONGRESS PKWY | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606123833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129424252 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2007 | ||||||||
LastUpdateDate: | 03/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036109245 | IL | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | MD00045000 | WA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 204F00000X | 036109245 | IL | Y |   | Allopathic & Osteopathic Physicians | Transplant Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 335890 | 01 |   | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 8430654 | 05 | WA |   | MEDICAID |