Basic Information
| Provider Information | |||||||||
| NPI: | 1629362223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHIU | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3231 EUCLID AVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023471 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087832000 | ||||||||
| FaxNumber: | 7087833656 | ||||||||
| Practice Location | |||||||||
| Address1: | 3860 W OGDEN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606232460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8725883000 | ||||||||
| FaxNumber: | 8725883001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036133617 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-133617 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036133617 | 01 | IL | STATE LICENSE | OTHER | FC4080800 | 01 | IL | DEA | OTHER | 1080328358 | 01 | IL | SPECIALTY BOARD | OTHER | 336094852 | 01 | IL | CS LICENSE | OTHER |