Basic Information
| Provider Information | |||||||||
| NPI: | 1598750549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAM | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 OAKMONT LN | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307892550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 ERIE CT | ||||||||
| Address2: | SUITE L500 | ||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603022566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087636478 | ||||||||
| FaxNumber: | 7083831793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 12/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 036043300 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 2160743632 | 01 | IL | BCBS PROVIDER ID | OTHER | 110044982 | 01 | IL | RAILROAD MEDICARE | OTHER | 036043300 | 05 | IL | MEDICAID | 363150672 | 01 | IL | OWCP PROVIDER ID | OTHER |