Basic Information
| Provider Information | |||||||||
| NPI: | 1588956635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | CHADRICK | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 MAIN ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616061907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094950201 | ||||||||
| FaxNumber: | 3096766545 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MAIN ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616061907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094950201 | ||||||||
| FaxNumber: | 3096766545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2011 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 36138899 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 036138899-1 | 05 | IL | MEDICAID |