Basic Information
| Provider Information | |||||||||
| NPI: | 1255528535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERES EDELSON | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., MS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | EDELSON | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | P | ||||||||
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| OtherCredential: | M.D., MS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 180 HARVESTER DR | ||||||||
| Address2: | SUITE 110, MC 1099 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605277594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738344740 | ||||||||
| FaxNumber: | 7738340946 | ||||||||
| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE | ||||||||
| Address2: | MC 5000, W312 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606371447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738342191 | ||||||||
| FaxNumber: | 7738342238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 05/27/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036111499 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036111499 | 05 | IL | MEDICAID |