Basic Information
| Provider Information | |||||||||
| NPI: | 1841405396 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDNA RICHARD M D | ||||||||
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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: | 2525 S MICHIGAN AVE | ||||||||
| Address2: | B390 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606162333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125676691 | ||||||||
| FaxNumber: | 3123287895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | RICHARD | ||||||||
| AuthorizedOfficialFirstName: | EDNA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3125676691 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2160083333 | 01 | IL | BCBS PROVIDER ID | OTHER |